
(1;iss K C 4>Cp 
Book , w S* 



PRESENTED 1SY 



/ 

THE 



Practice of Medicine. 

/ 

A HANDBOOK 



Practitioners and Students. 



M. CHARTERIS, M.D., 

PROFESSOR OF THE PRACTICE OF MEDICINE AND PHYSICIAN AND LECTURER ON 
CLINICAL MEDICINE, GLASGOW ROYAL INFIRMARY. 



WITH MICROSCOPIC AND OTHER ILLUSTRATIONS. 




PHILADELPHIA : 

P. BLAKISTON, SON & CO., 

1012 WALNUT STREET. 

1882. 



< 



Gift 

Miss Frances S.Hay 
July 18,1931 



The idea of compiling this Handbook was sug- 
gested by my own experience; and I have tried to 
write as one speaking to students. My aim having 
been to render it "handy" and practical, it is in 
many respects necessarily brief; and as I desired 
to present ascertained facts, some points still in 
dispute have been only incidentally mentioned, not 
discussed. 

I desire to record my special thanks to my friend 
and colleague Dr. A. M. Buchanan, and to my for- 
mer assistant and highly esteemed pupil Dr. T. O. 
Guthrie, for kind and willing assistance in preparing 
the sheets for the press. 

My obligations to Dr. Whittaker are seen in the 
illustrations. 

M. C. 



CONTENTS. 



PAGE 

General Diseases, ........ 13 

Fevers, 21 

Typhus Fever, 23 

Typhoid Fever, 27 

Relapsing Fever, 33 

Intermittent Fever, or Ague, 35 

Kemittent Fever, 38 

Yellow Fever, . 40 

• Dengue, Dandy Fever, Breakdown Fever, . . .42 

The Plague, 43 

Eruptive Fevers, 43 

Small-pox, 44 

Vaccinia, or Cow-pox, . .47 

Varicella, or Chicken-pox, ...... 48 

Scarlet Fever, 49 

Measles, 53 

Kubeola, Rotheln — German Measles, . . . .56 

Dropsy, .......... 58 

Tuberculosis, 62 

Syphilis, 67 

Rheumatism, ......... 70 

Gout, * 74 

Scurvy, 79 

Purpura, 82 

Chlorosis, Anaemia, 85 

Erysipelas, 87 



V1U CONTENTS. 

PAGE 

Diseases of Kespiratory Organs, .... 91 

Catarrh, 95 

Laryngitis, etc., 96 

Diphtheria, ......... 98 

Croup, 102 

False Croup, .106 

Hooping-cough, ........ 107 

Influenza, . . . . . . . . 110 

Acute Bronchitis, 112 

Chronic Bronchitis, 116 

Emphysema, 118 

Asthma, . . . . . . . . . . 121 

Pneumonia, . . . . . . . . 122 

Pleurisy, 129 

Chronic Pleurisy, 134 

Phthisis, Pulmonary Consumption, .... 136 

Acute Phthisis, 140- 

Cancer of the Lung, . . 142 

Diseases of the Circulatory Organs, . . . 142 

Angina Pectoris, 142 

Hypertrophy of the Heart, 144 

Atrophy of the Heart, 147 

Pericarditis, . . 148 

Endocarditis, 151 

Cardiac Murmurs, 152 

Palpitation of the Heart, . . % . . . . 159 

Thoracic Aneurism, 159 

Abdominal Aneurism, 161 

Ulcers of the Tongue, 163 

Stomatitis, . . . .164 

Mumps, Cynanche Parotidea, ...... 165 

Quinsy, Cynanche Tonsillaris, ...... 165 

Diseases of the (Esophagus, 166 

Dyspepsia, 166 

Gastric Ulcer, 169 



CONTENTS. 



IX 



Cancer of Stomach, . 
Constipation, .... 

Colic, 

Obstruction of the Bowels, 
Diarrhoea, ..... 
Dysentery, .... 

Epidemic Cholera, 
Intestinal Worms, 
Roundworms, .... 
Trichina Spiralis — Trichinosis, . 
Peritonitis, .... 

Chronic Peritonitis, . 
Typhlitis and Perityphlitis, 



Diseases of the Liver, . 

Painless Enlargements of Liver, 
Painful Enlargements of Liver, 
Contractions of the Liver, . 
Jaundice, 



Diseases of the Pancreas, 

Diseases of the Spleen, 
Leucocythsernia, 



Bronchocele, Goitre, .... 

Disease of the Suprarenal Capsules, Addison's Disease, 



Diseases of the Kidneys, 

Nephritis, 

Bright's Diseases, 

Acute Bright's Disease-, . 

Chronic Bright's Disease, 
The Large White Kidney, 
The Granular Contracting Kidney, 
The Waxy Kidney, . 

B 



X CONTENTS. 

PAGE 

Uraemia, 231 

Chylous Urine, • . .232 

Hematuria, 233 

Haematinuria, 235 

Gravel, Renal Calculus, or Colic, 236 

Diabetes, 237 



Diseases of the Neryotjs System, 








243 


Cerebral Anaemia, 








244 


Cerebral Congestion, . 








245 


Cerebral Embolism and Thrombosis, 








246 


Cerebral Haemorrhage, 








247 


Apoplexy, 








250 


Cerebral Softening, 










252 


Sclerosis, 










253 


Aphasia, 










254 


Acute Meningitis, 










256 


Tubercular Meningitis, 








257 


Chronic Hydrocephalus, 








258 


Encephalitis, .... 








259 


Tumors of Brain, 










259 


Paralysis, . 










260 


Neuralgia, . 










267 


Epilepsy, 










269 


Chorea, 










274 


Delirium Tremens, 










276 


Sunstroke, . 










279 


Hysteria, 










279 



Diseases of the Spinal Cord, 283 

Locomotor Ataxy, . . * 286 

Cerebro-Spinal Fever, Epidemic Cerebro-Spinal Men- 
ingitis, ......... 288 

Hydrophobia, . . . . ' '■ % . . . .289 

Tetanus, 291 



CONTENTS. XI 

PAGE 

Diseases of the Skin, 292 

Erythema, 296 

Roseola, 297 

Urticaria, 297 

Sudamina, 298 

Herpes, 298 

Eczema, 299 

Pemphigus, 300 

Rupia, 300 

Impetigo, ......... 301 

Ecthyma, 301 

Lichen, 302 

Prurigo, 302 

Psoriasis, 303 

Pityriasis Rubra, 303 

Acne, 304 

Lupus, ......... 304 

Parasitica, 306 

Scabies, 306 

Tinea Favosa, . . . ... . . . 307 

Tinea Tricophytina, . . . . . . . 307 

Tinea Decalvans, Alopecia Areata, .... 308 

Tinea Versicolor, 308 

Appendix, 309 

Index, . 327 



GENERAL CONSIDERATION OF DISEASE, 



WITH 



BEDSIDE HINTS. 



What is health ? The answer to this inquiry can 
scarcely be given in the form of a definition, yet it 
requires no medical education to suggest a picture of 
what health is at the typical eras of human existence, 
when all the various functions of the human body are 
performed easily, naturally, and well. The healthy 
individual breathes without difficulty, the food taken 
is relished and properly assimilated, the blood is forced, 
from its centre — the heart — onwards over the body, 
without valvular flaw or subsequent hindrance, and 
the brain, with its nervous expansion undisturbed 
by morbid fancies, controls the movements and the 
thoughts of the living organism. Disease is a devia- 
tion, to a greater or less extent, from what we thus 
realize, though we cannot define, as the standard of 
health. It may invade one or more of the systems 
we have alluded to, and it is the duty of the physi- 
cian to find out, by the varied appliances of his art, 

2 



14 GENERAL DISEASES. 

what and where the disease is. Thus the student will 
perceive, what practical bedside experience teaches, 
that diseases are to be referred in many cases to 
certain systems — viz., respiratory, circulatory, diges- 
tive, integumentary, genito-urinary, and nervous ; 
each of these systems being liable to various diseases ; 
and the allocation to one of these systems having 
been made, it is the further province of the physician 
to ascertain, by a careful examination of the phenom- 
ena presented to him, what the particular disease 
wdiich he is investigating may be. A little reflection 
or experience will, however, convince the student that 
all diseases cannot be brought under such a simple 
classification. There are certain diseases, by no means 
the least important, which, though presenting well- 
marked features during life, are found, by examina- 
tion after death, not to have involved any one particu- 
lar system. These must be called, for the want of a 
better term, General Diseases. The exact idea ex- 
pressed by this will be better understood when these 
diseases are individually considered. 

"When we are called to investigate real or imagin- 
ary disease, the question presents itself to us, How is 
the nature of the disease to be determined ? How is 
the inquiry to be prosecuted ? 

Pain is a prominent feature in disease, and im- 
portant information may be obtained by asking, 

" Where do you feel pain?" Follow this up by 
further inquiring, 

" How long have you been ill ?" 

The patient in this way refers his pain to some 



GENERAL DISEASES. 



15 



particular part or parts, and tells the story of his ill- 
ness in his own words, without any promptings on 
your side, which may be misleading. Now, with 
certain data to go upon, and with no preconceived, 
and therefore probably erroneous, ideas directing you, 
the systematic investigation can be justly commenced. 
If attention is directed to the chest, that region must 
be carefully explored, by the three great means of 
auscultation, percussion, and palpation. In order 



Fig. 1. 




to facilitate inquiry, and to localize its evidences, the 
chest has been divided into certain regions, as the 
accompanying diagram will at once show; a fact 
which beginners should realize, not merely by looking 



16 • GENERAL DISEASES. 

at it, but by drawing the corresponding lines in ink 
on a friend or fellow-student's chest. 

In percussion the pleximeter and hammer may be 
used, or, in lieu of them, the first two fingers of the 
left hand may be applied flatly to the chest, and 
struck with the tips of corresponding ones of the 
right. Being already familiar with the sounds in 
health, you compare one region with the correspond- 
ing region on the opposite side, and note whether the 
sounds produced by percussion are healthy or the re- 
verse, abnormally dull or abnormally clear. 

Proceed in a similar way with auscultation, by 
means of the stethoscope, after carefully reading the 
chapter on Respiratory Sounds in Health. 

Palpation and mensuration will enable you to tell 
the exact dimensions, say of dulness, and the differ- 
ence in this respect between opposite sides. 

But supposing your patient does not refer his com- 
plaint to the chest, but to the stomach, then your 
inquiry must be directed primarily to the digestive 
system. Examine the tongue, ask as to his appetite 
and the state of the bowels. Percussion and men- 
suration are now of great importance. The abdomen 
has also been divided by lines, as in the accompanying 
diagram. 

If the patient refers his ailment to the kidneys or 
the bladder, your inquiry must be particularly di- 
rected to the urine, for this is the keynote to diag- 
nosis. Note its color, take its specific gravity, etc. 
(See chapter on Urinary Diseases.) 



GENERAL DISEASES. 



17 



If he refers his complaint to the nervous system, 
try to discover from the symptoms presented what 
disease it may be, remembering that the brain is an 
aggregation of various parts, and that the means which 



Fig. 2. 




assisted you before are now of little avail, — " For the 
brain you can neither see, nor touch, nor handle." 
The subject is thus beset with greater difficulty than 
in the case of the other systems mentioned. 

It is a matter of great importance, in the method 
of examination thus suggested, to remember that one 
system cannot be long involved without implicating, 
to a greater or less extent, some if not all of the 
others. While special attention is of course paid to 
the system containing the organ primarily diseased, 
it is essential that the others should not be forgotten. 



18 



GENERAL DISEASES. 



It is immaterial in what order they are considered, 
but it is essential that no one of them be neglected ; 
and it is astonishing how, after a little experience, 



Fig. 3. 




the student quickly and instinctively goes over them 
all. 

Negatively, " General Diseases" may be remembered 
as not being brought under the systems mentioned ; 
positively, they are associated with a constitutional 
state and have a. history of their own. Under the 



GENERAL DISEASES. 19 

head of "General Diseases" are included what are 
termed zymotic diseases, or diseases which it is sup- 
posed can be prevented by attention to hygienic or 
other conditions. Zymotic diseases are distinguished 
by the following characters: "They are all of them 
febrile diseases. They all run naturally a definite 
course in definite though different periods of time. 
They all present during some (usually definite) portion 
of that course certain distinctive spots, making erup- 
tions on the surface of the body. As a rule, broken 
and proved by rare exceptions, they occur once only 
in the same person. Lastly, they are communicable 
from person to person by contagion, and arise in no 
other way. 

" Small-pox, chicken-pox, typhus fever, typhoid or 
enteric fever, scarlet fever, the plague, measles, hoop- 
ing-cough, mumps, constitute zymotic diseases." (Sir 
Thomas Watson.) 

In investigating these diseases it will be found that 
they appear to be propagated by some unknown 
though probably atmospheric influences, owning no 
general law, spreading over a wide area (epidemic), or 
peculiar to certain fixed localities (endemic). Under 
" General Diseases " it will thus be seen are numbered 
the various fevers, some of which seem the offspring 
of filth and the neglect of sanitary laws; while others 
depend on a specific something which is transmitted 
from person to person, probably through a disease- 
germ, and which, through its specific character, can 
originate only the disease from which it sprang. 

Under " General Diseases" also are included various 



20 GENERAL DISEASES. 

states of the body, in which the blood seems chiefly 
implicated, and which reveal themselves by local and 
constitutional and characteristic symptoms, as will be 
pointed out when individually considered. 

The student therefore, in forming an opinion with 
regard to diseases connected with the various systems, 
or with regard to general diseases, will see that an 
important element in this opinion or diagnosis must 
be the causation, the etiology, of the disease in ques- 
tion. Is it peculiar to one country or to many ? Is 
it a disease of youth or age? Is it hereditary, or is it 
acquired ? Is it dependent on known or unknown 
agencies ? Is it characteristic of sex or occupation ? 

Having thought these things over, having gleaned 
what he can also from signs, symptoms, and history, 
his further duty is to form a prognosis, a forecast of 
the probable issue. Will it be fatal, or the reverse ? 
What complications may arise, and how may these be 
averted ? These, and all previous considerations have 
one definite object in view, viz.: Treatment, specially 
directed to the person who is ill, but also in certain 
cases prophylactic, i. e., guarding against the extension 
of the disease to others, if that be possible. We now 
take up the first great class of diseases. 



FEVERS. 21 



FEVERS. 



Fever, generally expressed, is that state of the 
body in which, after an incubation stage of more or 
less duration, symptoms of debility and shivering su- 
pervene, and these afterwards give place to great heat 
of body, quickened pulse, and disturbance of most of 
the functions. 

Or, fever may be shortly defined as that state of 
the body in which there is an increase of temperature 
above the normal (Virchow). The temperature is 
taken by the clinical thermometer, which is introduced 
and kept in close contact with the axilla from ten to 
fifteen minutes, after which it is withdrawn, and the 
increase from the standard of health, 98.6°, is noted. 
In fever the temperature should always be carefully 
taken morning and evening, and, in hospital, a chart 
indicating the daily result from the commencement 
should b.e hung up in a convenient situation near the 
bed. 

In this country there are four kinds of continued 
fever — 

1. Simple fever or febricula. 

2. Typhus. 

3. Typhoid. 

4. Relapsing. 

Simple fever or febricula is non-contagious, and 
depends frequently on errors of diet, exposure to the 



22 FEVERS. 

sun or cold, or other insanitary agencies which may 
fatigue or weaken the system. 

Symptoms. — Following on one or more of these 
causes, without almost any warning, the patient be- 
comes languid and disinclined for either mental or 
bodily work ; the appetite is lost, and headache en- 
sues; a dull aching pain is felt all over the body, es- 
pecially at the back, accompanied with " a creepy cold 
sensation," difficult to define. 

This creepy cold sensation is followed, in the course 
generally of a few hours, by increased heat of body 
(fever), rapid pulse, furred tongue, and scanty high- 
colored urine. Delirium, through sleeplessness, may 
supervene, and the state of matters may seem very 
alarming, when, after an interval of three or four days, 
there is a crisis. The pulse falls, the skin becomes 
moist, thirst abates, headache ceases, and a copious 
perspiration terminates the fever. The patient is left 
weak, yet convalescent, and the strength gradually 
returns. 

Prognosis. — This fever is rarely dangerous. It may 
be added that its division into catarrhal, bilious, mes- 
enteric, and brain fever seems unnecessary. 

Treatment — The indications for treatment, since 
the fever terminates in recovery, may be summed up 
in a few words. At the commencement give a saline 
purgative of sulphate of soda and sulphate of mag- 
nesia, or a seidlitz powder. After the bowels have 
acted, employ a diaphoretic or diuretic mixture (F. 
31, 40). The patient has no inclination for solid food, 
and should not be urged to take anything but a sloppy 



TYPHUS FEVER. 23 

diet, as arrowroot, milk, gruel, etc. Convalescence is 
to be assisted by nourishing food, such as beef tea, 
chicken soup, and wine. A tonic mixture is also ser- 
viceable (F. 75, 76, 77). 

Typhus Fever. 

The terra typhus is derived from the Greek word 
TOfoq, smoke. It was formerly called putrid, pesti- 
lential, jail, ship, or hospital fever. 

Etiology. — This fever is contagions, usually epi- 
demic, and most frequently follows or is the direct 
result of destitution, overcrowding, and bad ventila- 
tion. It is eminently a disease of the poor. 

Symptoms. — The fever poison having been absorbed 
into the system, there is a period of incubation from 
one to twelve days, during which time the patient 
feels out of sorts, with pains in his limbs, languor, 
loss of appetite, headache, thirst, and the " creepy 
sensation " formerly alluded to. These are succeeded 
after a varying interval by increased heat of skin, full 
and rapid pulse, restlessness, apathy, great thirst, and 
prostration. The patient no longer fights against his 
malady, but willingly keeps his bed. 

Is there anything particularly characteristic of this 
fever ? 

There is what is termed the typhus rash, somewhat 
dark and mulberry in appearance. It consists chiefly 
of irregular spots, sometimes single and easily defined, 
at other times patchy from a number of them coales- 
cing. They are most frequently seen on the chest and 



24 FEVERS. 

abdomen, rarely on back or face, and at first disappear 
on pressure. Their dark color fades after a day or 
two into a brickdust hue or mottling, which appear- 
ance increases until the rash becomes ecchymosed or 
hemorrhagic, and in this later stage does not disap- 
pear on pressure, but remains permanent even after 
death, or until recovery ensues. The rash comes out 
once for all, not gradually, from the fifth to the eighth 
day of the fever, and is rarely absent in adults, although 
in young children it is not so frequently observed. In 
addition to this rash, characteristic of typhus fever, 
there is also peculiar to it a dull, heavy, stupid expres- 
sion of countenance. The eyelids droop, and the eyes 
have the appearance of those of a man recently re- 
covered from a debauch. 

With the fever there is generally delirium. This 
rarely comes on before the end of the first week, and 
usually continues until death or convalescence super- 
venes. The delirium is of a violent and painful char- 
acter, and at first is not continuous. The patient can 
be roused to answer questions, take drinks, or show 
his tongue. Yet his expression is vacant, and he mut- 
ters when alone. Generally this stage is succeeded by 
a loss of cognizance of external objects, and all kinds 
of illusions, especially during the night. The patient 
tosses about from side to side, or he may shout madly, 
or endeavor to get out of bed. The mind is, in one 
word, thoroughly unhinged. 

The pulse increases in rapidity, and at the same 
time gets more soft and feeble. The temperature rises 
in the first week to 104° or 105°, remaining about 



TYPHUS FEVER. 25 

these points for a week, and then subsiding to the nor- 
mal or subnormal about the end of the second week. 

The tongue becomes dry, brown, tremulous, and is 
protruded with difficulty, while the teeth and lips are 
covered with sordes, emaciation all the time going on, 
with tendency to contraction of the pupil, cold ex- 
tremities, and congested conjunctivae. 

The crisis is reached on the fourteenth day from the 
commencement of the fever, and is ushered in by a 
prolonged sleep, by diarrhoea, or by profuse sweating, 
or there may be no marked crisis, but rather a gradual 
subsidence of pulse and temperature (a lysis). 

Should a fatal termination ensue, it usually happens 
between the twelfth and the twentieth day of the fever, 
death being preceded by great prostration, picking of 
the bedclothes, subsultus tendinum, involuntary pass- 
ing of feces and urine, and coma. The mortality is 
about one in five of those attacked, and the greater 
the age above ten years the greater the danger. 

Complications. — Typhus may be complicated by the 
occurrence of acute bronchitis, pleurisy, or pneumonia, 
rarely by affections of the larynx or pharynx. The 
heart is sometimes softened, especially the left ventri- 
cle, and this gives rise to depressed action of the organ, 
and a loss of the first sound. At other times the 
sounds are well developed, and are accompanied by a 
vigorous and heaving impulse, indicating over-excite- 
ment of the organ without softening. Other compli- 
cations are gangrene of the extremities, bedsores, very 
rarely diarrhoea — the bowels all through the disease 
rather being constipated. 



26 FEVERS. 

Diagnosis. — The rash and the nature of the fever 
distinguish typhus from any inflammatory condition 
of the lungs. Its further diagnosis from typhoid will 
be alluded to afterwards. Acute meningitis, for which 
it has been mistaken, is attended with nausea and vom- 
iting, no rash, and delirium almost from the commence- 
ment. 

Morbid, Anatomy. — There is nothing characteristic 
in the postmortem appearances of a fatal case of ty- 
phus fever. If there has been marked delirium we 
may expect to find the sinuses engorged, but in the 
majority of cases the brain is seldom altered. The 
spleen is softened, and in some cases enlarged. The 
heart may be somewhat atrophied, and the blood fluid. 
Should there have been an inflammatory condition of 
the lungs, indications of this will of course be found 
on examining the thorax. The intestinal tract is 
healthy. 

Treatment.- — In the early incubatory stage, Dr. 
Hughes Bennett recommended an emetic, which he 
said had saved him from one or two attacks, when he 
was certain the poison was in his system. If this stage 
be over we must treat symptoms, remembering that 
we may guide, but can never cure a fever. A purga- 
tive of thirty to sixty grains of rhubarb may be given 
at the outset. Tepid water injections relieve after- 
constipation. The apartment should, if possible, be 
large and well ventilated, with a fire in the room. 
Intercourse with friends should be restricted, and at- 
tendance limited to skilled nurses. The head should 
be shaved, or the hair teased out, and cold lotions ap- 



TYPHOID FEVER. 27 

plied. The diet should consist chiefly of milk and 
weak broth. 

Stimulants may be needed to tide over the dis- 
ease, and should be administered when there is signal 
loss of strength, or rapid feeble pulse, and weakness 
of the first sound of the heart. If it is found that 
the temperature does not increase, that the pulse be- 
comes fuller, and the general condition improved, 
brandy may be given in teaspoonful or tablespoonful 
doses every two hours. Care must be taken to give 
it at certain intervals, and if necessary the patient 
must be roused to take it. A mixture of chloral and 
bromide of potassium is beneficial, especially at the 
approach of the crisis, if there is great irritability and 
sleeplessness (F. 69). 

Bedsores must be prevented from forming, and 
attention should also be directed to the bladder. 

The pulmonary complications must be met if they 
arise by local and general treatment. 

Cold baths at about 65° Fahr. have been strongly 
recommended lately, and may be repeated day and 
night when the temperature rises above 102° Fahr. 

Typhoid Fever. 

Etiology. — The term typhoid literally means like 
typhus. It has also been termed enteric, gastric, or 
pythogenic fever. It is not, like typhus, markedly 
contagious, and it seems to be generated from bad 
drains, sewage gas, or fluids contaminated by sewage. 

Symptoms. — The patient is attacked by the disease 



28 FEVERS. 

more insidiously than in typhus. There is no abrupt 
departure from health to disease. There may be a 
slight premonitory chill, followed by malaise and in- 
ability or aversion to work. The man feels out of 
sorts, and attends listlessly to his business ; the child 
inclines to rest, and not to play with its toys. Then 
lying in bed is found to be a welcome relief, and there 
is no inclination to leave it. At the early stage of 
typhoid, as well as during the whole continuance of 
the fever, the thermometer is found to be of great 
value. Thus, even although the pulse indicates little 
deviation from health, it will be found that the even- 
ing temperature is higher than the morning by about 
a degree, 99.9° morning, 100.5° evening ; and this 
characteristic of a high evening temperature com- 
pared with that of the morning is retained through- 
out the disease. The temperature rises gradually, and 
may reach 105° towards the end of the first week, 
after which it agains slowly falls to reach the normal 
state, by a series of oscillations between the morning 
and the evening temperatures, which may continue for 
an indefinite time, extending even to weeks after other 
symptoms have gone. The general symptoms qf fever 
are present — as thirst, loss of appetite, and headache. 
The tongue loses the color of health and becomes 
small and dry, having a pale brownish-yellow fur, 
with red tip and edges. 

About the seventh or eighth day of the fever small 
rose-colored spots sometimes, but not invariably, ap- 
pear on the abdomen, chest, or limbs, being situated 
on normal uncolored skin. They may be few in nurn- 



TYPHOID FEVER. 29 

ber or numerous. Their form is circular, and they 
last three days, disappearing completely under pres- 
sure, to reappear when that is removed. Fresh crops 
succeed those previously formed until the termination 
of the fever. They are rarely seen after the thirtieth 
day unless a relapse occurs. 

The abdomen becomes somewhat enlarged, and on 
careful pressure over the right iliac fossa a gurgling 
sound is generally heard, with distinct wincing or even 
actual pain. Even when delirium is present this 
wincing is usually seen by looking at the face. 

Diarrhoea is almost always present. In some cases 
the stools are numerous, in others only two or three 
in the day. The color of the stools is characteristic, 
and is best described as being like that of pea-soup. 
Occasionally they are tinged with blood. With diar- 
rhoea there may be marked distension of the abdomen 
and tympanitis. 

Coarse and Progress of the Disease. — The disease 
may end in recovery or death. If the former, after 
the twenty-first day the severity of the symptoms 
abates, and gradual convalescence ensues. The tem- 
perature falls, presenting a gradual approximation of 
that of' the evening and that of the morning. If the 
latter, the patient may sink exhausted and worn out 
by the disease, or fatal haemorrhage may ensue, or 
peritonitis from perforation through the ulcerated spots 
on the small intestine. As in typhus, acute inflam- 
matory disease of the chest may complicate matters 
and be the more immediate cause of death. Again, 

3 



30 FEVERS. 

death may occur from inflammation arising from ab- 
sorption of fetid matter from ulcerated bowels. 

Morbid Anatomy, — Characteristic traces of the dis- 
ease are found after death, and are pathognomonic of 
typhoid fever. These are altered appearances of 
Peyer's patches and the adjacent mesenteric glands, 
and the lesions are most distinct in the group of glands 
nearest the ileo-csecal valve. If the disease termi- 
nates fatally before the fever has advanced far, we may 
find the mucous membrane over the glands simply 
congested and swollen. If, as most commonly hap A 
pens, death results at a later stage, this congested ap- 
pearance is succeeded by the detachment of the slough 
as a whole, or molecularly, leaving ulceration, with 
ragged irregular edges, varying in size from a pea to a 
florin. This ulceration may even go on to a perfo- 
ration. The mesenteric glands in the neighborhood of 
the patches are enlarged and softened. 

Diagnosis. — Typhus and typhoid fever are both dis- 
tinguished from febricula and relapsing fever by the 
longer continuance and course of the fever, along with 
the characteristic eruptions, and from one another by 
the following symptoms : 

1. In typhus the rash is mulberry, mottled, and 
continuous, going on to ecchymosis, and hence resisting 
pressure. In typhoid the rash consists of rose-colored 
spots, fading in three days, and giving place to a fresh 
crop. These spots disappear on pressure, and are not 
surrounded by mottled skin. 

2. In typhus the rash appears from the fifth to 



TYPHOID FEVER. 31 

the eighth day. In typhoid between the seventh and 
the fourteenth. 

3. In typhus there is no diarrhoea. In typhoid diar- 
rhoea is common, and the stools are of a pea-soup 
color. 

4. In typhus the symptoms are generally cerebral; 
hence disquietude going on to coma, with an inter- 
mediate stage of delirium. In typhoid the symptoms 
are abdominal ; hence diarrhoea, and pain on pressure 
over right iliac fossa. In typhus we see contracted 
pupils, muttering delirium, preceded by disquietude 
and uneasy manner, and congested conjunctivce. In 
typhoid we see dilated pupils, delirium, preceded by 
apathy and somnolence, and no congestion of the con- 
junctiva?. 

5. These fevers also differ in their duration, a crisis 
being reached in typhus on the fourtrenth day of the 
fever ; while in typhoid, not a crisis, but a lysis, is 
reached on the twenty-first day. Typhus may occur 
at any age, and is commonest amongst the poor. Ty- 
phoid is generally a disease of youth or adult life, is 
rare after forty, and it shows no partiality to the 
poor. 

Treatment. — A teaspoonful of ipecacuan wine may 
be given every ten minutes until vomiting ensues, if 
the patient is seen in the early stage, and before the 
spots have appeared. Purgatives should be avoided. 
After the disease has been established, it is necessary 
simply to watch and treat symptoms. 

Should the diarrhoea be excessive or weakening, 
astringents may be given. There is not the same 



32 FEVERS. 

necessity for caution as in typhus with regard to the 
administration of opium, and the drug may be given 
either by the mouth or rectum ; if in the former way, 
combined with catechu (F. 17); in the latter, in the 
starch and laudanum injection. Should haemorrhage 
occur, gallic acid is requisite, with brandy if there be 
great depression and exhaustion ; or the pil. plumb, 
cum opio, turpentine, or the subcutaneous injection of 
ergotin may be tried. Delirium and sleeplessness 
may necessitate sedatives, such as chloral, the bromide 
of potassium, or both combined. Tincture of hyoscy- 
amus is also serviceable. All physical restraint should 
be forbidden, as patients are generally easily coaxed 
by a kind and skilful nurse to do what is requisite. 
Good ventilation, careful sanitary arrangements, clean- 
liness, and prevention of bedsores, should be matters 
of routine. 

The diet is of paramount importance. Nothing 
can be better than milk, and of this the patient may 
drink ad libitum at regulated intervals. On the re- 
turn of convalescence the patient should be warned 
against rising too soon, or changing the milk diet, or 
supplementing it by other. food. It must be remem- 
bered that the ulcers are now cicatrizing, and any 
error in diet may prevent this, and bring on alarming 
symptoms ; besides, relapses are not uncommon. An 
addition may gradually be made to the milk by a 
little weak soup or broth. Then give arrowroot with 
dry toast, and finally, beef tea ; although the latter 
should be avoided if there is any tendency to diarrhoea. 
No solid food should be ordered until the tongue is 



RELAPSING FEVER. 33 

clean, all pain on pressure over the iliac region gone, 
and the temperature normal. 

Finally, it must be remembered that a careful ther- 
mometry chart of the temperature, as taken morning 
and evening, is the only satisfactory index of the 
fever. 

Liebermeister strongly recommends the use of a 
bath at 68° Fahr., of ten minutes' duration, if the 
temperature reaches or exceeds 102°, with quinine in 
the dose of 24 grains. In very severe cases he advises 
digitalis to be added to the quinine. In this way the 
high temperature is controlled. The statistics given 
of the results of this treatment seem very satisfactory. 

Relapsing Fever, 

Known also as recurrent typhus or famine fever, 
was long confounded with typhus ; the differential di- 
agnosis between them being only made by Jenner in 
1850. 

Etiology. — It is intimately allied to typhus, being 
highly contagious, and originating from filth, over- 
crowding, and destitution. Lebert and other German 
observers find in the blood of relapsing fever patients 
thin threadlike spiral fungi. These are supposed to 
enter the system either directly or through the taking 
of fluids or solids. The period of incubation is from 
five to seven days. It is most common in early child- 
hood, and from the 20th to the 30th year. Between 
30 and 50 it is rare ; and after 50 it is scarcely ever 
seen. 



34 FEVERS. 

Symptoms. — Unlike the other fevers mentioned, 
there are no forewarners. The disease sets in sud- 
denly with headache and intense fever, which at once 
prostrate the patient, and it is accompanied with 
thirst, loss of appetite, pain in limbs, and burning 
heat of skin. The temperature for the first two days 
is usually 102° morning and 104° evening, and then 
it mounts to 105° and 107°. The pulse is weak and 
quick, and the skin moist. The tongue is thick and 
coated ; not parched and black as in typhus. The 
bowels are constipated. 

On the second day the liver atid spleen, especially 
the latter, notably enlarge, — not merely from day to 
day, but from morning to evening. There is little 
delirium. The high fever, the rapid loss of strength, 
the splenic enlargement, indicate a fever likely soon 
to be fatal ; when, as suddenly as it came, on the fifth, 
sixth, or more usually, on the seventh day, there is a 
crisis, with profuse sweating, rapid fall of tempera- 
ture, and complete improvement of all the symptoms, 
with entire decrease of the splenic enlargement. The 
only thing left is great languor, which sometimes may 
approach syncope. 

This interval of freedom lasts usually a week, when 
a relapse occurs, generally at night, with all the symp- 
toms which characterized the previous attack. This 
attack is, however, shorter, lasting only three or five 
days. It suddenly ceases, leaving the patient weak 
and anaemic, and entailing a lingering recovery of 
from four or five to six weeks. As many as four or 
five relapses have been known. 



INTERMITTENT FEVER, OR AGUE. 35 

Prognosis and Complications. — In only two or three 
per cent, of the cases is the fever fatal. Death may 
occur from the intensity of the fever, or from compli- 
cations, as pneumonia or abscess of the spleen. 

Post-mortem Appearances. — If death occur from the 
disease, the spleen is found greatly enlarged, the cap- 
sule tense, the parenchyma soft and pulpy, with wedge- 
shaped impactions due to emboli. The liver and kid- 
neys are also congested. Nothing of special note is 
observed in the other organs. 

Treatment. — Rest in bed, cleanliness, milk, strong 
soup, and wine, are necessary. A bladder of ice may 
be applied to the head, to relieve headache, and w T ater 
charged with carbonic acid given to allay thirst. For 
splenic pain apply cold applications or continuous 
poultices. 

Ten drops of dilute phosphoric acid should be 
given in sweetened water every two hours; if symp- 
toms of collapse, carbonate of ammonia and alcohol ; 
if delirium, 15-grain doses of chloral every hour, 
until one or two drachms have been taken. 

During convalescence good nourishing diet, with 
wine, and the preparations of quinine and iron, are 
essential. 

Intermittent Fever, or Ague. 

These fevers constitute a class by themselves, and 
were well known to the ancients. 

They are dependent ou certain marshy miasms, and 
are endemic, not epidemic, in character. 



36 FEVERS. 

The febrile phenomena occur in paroxysms, ushered 
in by rigors, and terminate by a critical sweat. 

There are three distinct changes : 1, a stage of chill ; 
2, of heat; 3, of sweat. 

The fevers are divided into types according to the 
length of these stages, for the attacks occur pretty 
regularly — every twenty -four hours (quotidian); every 
forty-eight hours (tertian); every seventy-two hours 
(quartan). 

The time between the commencement of one par- 
oxysm and the beginning of the next is termed the 
interval. That between the termination of one par- 
oxysm and the commencement of the next the inter- 
mission. 

The type most common in temperate climates is 
the tertian. 

Etiology, — While the predisposing causes are those 
which weaken the system, as exhaustion, insufficient 
food, intemperance, or exposure to night air, the ex- 
citing causes are certain peculiar invisible emanations, 
undetected by chemistry or the microscope, which are 
known as malaria, and spring chiefly from marshy 
lands. Most probably decomposing animal and vege- 
table matters furnish the materies morbi, chiefly, if 
not entirely, the latter; for it is an established fact 
that ague in time past was common in certain tracts 
of country then uncultivated, whereas now, since the 
land has been purified by agriculture, the disease is 
unknown. 

Symptoms. — The invasion may be sudden or after 



INTERMITTENT FEVER, OR AGUE. 37 

a few da) r s of indisposition, with headache, loss of 
appetite, and sneezing. 

The cold stage is characterized by chilliness, first in 
the limbs and afterwards over the whole body, with a 
sensation of streams of cold water running dow T n the 
back ; shrivelled skin, " cutis anserina," chattering of 
the teeth, blueness of the nails, hurried respiration, 
and small pulse. 

The duration of this stage varies from half an hour 
to three or four days, and is succeeded by the hot 
stage or reaction, with increased temperature, dry 
skin, great thirst, frequent pulse, and a peculiar ful- 
ness about the head. 

This hot stage usually lasts from three to four hours, 
but it may be prolonged to six, eight, or twelve hours, 
and is then followed by the sweating stage, beginning 
with a diminution of the heat, followed by a gentle 
moisture on the forehead and breast, and terminating 
in a copious sour-smelling steaming sweat, with an 
abundant flow of urine, normal pulse, and a cessation 
of all pain or uneasiness. 

This stage in its duration cannot be easily deter- 
mined, but it appears materially to exceed the other 
two. 

The fever thus described rarely results directly in 
death, but it often induces permanent enlargement of 
the spleen with induration, popularly known as the 
ague cake. The enlargement is a pure hypertrophy 
— that is, an enlargement of every element of the 
organ, and is accompanied by a peculiar cachexia. 

There is also congestion and permanent morbid 
4 



38 FEVERS. 

change in the liver, with serious disturbance of all the 
digestive organs. The patient is subject to cachexia 
from enlargement of spleen, and even after his recov- 
ery from that he is much more subject to recurrences 
of the fever, which do not necessarily require new ex- 
posure, but the periodic character may imprint itself 
upon other diseases, as epilepsy or neuralgia. He 
seems to carry the seeds about with him. 

Treatment. — In the cold stage the patient should be 
placed in bed, covered with blankets and rugs, with 
hot bottles applied to his feet, and hot drinks, such as 
tea or weak negus, should be given. 

In the hot stage cooling drinks are required, and 
the body should be sponged with tepid or cold water. 

In the sweating stage great care must be taken to 
prevent chills, and the action of the skin should be 
encouraged by tepid drinks. 

During the intervals quinine should be given in a 
large dose, 20 to 30 grains, either before or at the 
close of the paroxysm. 

Remittent Fever 

Appears to be dependent on the same causes as inter- 
mittent fever, viz., malaria. It is also endemic, non- 
contagious, and chiefly confined to tropical climates. 
The different localities in which it prevails have led 
to its being designated by various names. It is thus 
called Walcheren fever, Bengal fever, bilious remit- 
tent of the West Indies, jungle or hill fever of the 
East Indies, African fever, Mediterranean fever, etc. 



REMITTENT FEVER. 39 

The symptoms resemble those of intermittent fever; 
it is distinguished from it, however, by the notable fact 
that in the intervals there is no entire cessation of the 
fever, but simply an abatement or diminution. The 
disease continues from twelve to fourteen days, and 
the period of remission varies from six to twelve or 
fourteen hours. It is worthy of note that a distinct 
sliding scale of periodicity can be traced from inter- 
mittent fever down through remittent to the severe 
tropical continued fevers. 

Symptoms. — The fever is ushered in with gastric 
symptoms, uneasiness, depression, and sinking at the 
epigastrium, with headache and languor. The cold 
stage is scarcely marked, or, if so, is rapidly succeeded 
by a severe hot stage, with burning skin, vomiting, 
sleeplessness, intense headache, or even delirium. 
This stage, usually lasting the time mentioned, is suc- 
ceeded by an indistinct stage of sweating or subsi- 
dence, and is followed by another attack similar to 
the first but more severe. These attacks and varying 
remissions constitute the fever, which terminates in 
recovery or death, often in permanent ill health. Oc- 
casionally there is jaundice, and the liver and spleen 
are enlarged and tender. The remissions usually set 
in during the morning, while the exacerbations take 
place towards the evening. 

Treatment. — The object of treatment is to mitigate 
the exacerbations, and lengthen the remissions, and is 
based on the same principles as those indicated in in- 
termittent fever. Thus see that the bowels are acted 
on, sponge the body, or use the cold pack, and give 



40 FEVEKS. 

effervescing and saline drinks. When the remission 
occurs, give quinine in doses varying from four to six 
grains every three hours, omitting the remedy when 
the hot stage commences, but resuming it at the next 
remission. Cold should be applied to the head if the 
headache is severe, and sinapisms to the stomach to 
relieve the gastric irritation. If there be much ex- 
haustion, stimulants should be freely given. 

At the termination of the disease, the patient should, 
if possible, be sent to a temperate climate, or a non- 
malarious district. 

Iii very chronic cases fresh air and outdoor exercise 
seem to be beneficial, with the administration of iron. 
Dr. McLean highly recommends the use of the binio- 
dide of mercury ointment over the spleen, which has 
the advantage of never causing salivation. 

Yellow Fever 

Requires an average temperature of at least 72° 
Fahr. for some weeks to produce its appearance, and 
seems peculiarly to affect the West Indies, Africa, and 
some parts of America. 

It varies in severity, frequently terminating in death 
either by the acuteness of the fever, or by the exhaus- 
tion or intercurrent complications, such as ursemia or 
apoplexy. It is sometimes epidemic, and it is a matter 
of dispute whether or not it is contagious. It appears 
to be dependent on some morbid poison, probably of 
malarial origin. 

Symptoms. — The fever commences abruptly, often 



YELLOW FEVER. 41 

in the middle of the night, and is attended with severe 
headache, great irritability of the stomach, with vomit- 
ing, and a peculiar yellowness of the skin ; the vomited 
matters at first being slimy and- tasteless, but after- 
wards black like coffee-grounds — hence. called black 
vomit. The urine is frequently suppressed; if passed 
it is loaded with albumen and tube-casts, and is smoky 
in appearance. The fever usually lasts from three to 
five or seven days. 

When the sixth day elapses without the occurrence 
of black vomit or suppression of urine, hopes of re- 
covery may be entertained. The mortality is usually 
one in three. 

The symptoms of the fever point to the poison 
specially affecting the liver, which is supposed to un- 
dergo acute fatty degeneration. The poison is con- 
sidered to produce certain specific changes in the blood, 
viz., destruction of the red corpuscles. . The blood 
thus loses its capacity for nourishing and regenerating 
the tissues, and when death does not take place there 
is a lingering convalescence, consequent on the feeble- 
ness of the whole organism. 

Treatment. — Although yellow fever is dependent on 
malaria like the preceding fever, it is to be remem- 
bered that the spleen does not seem to be affected, and 
hence, probably, quinine is of little service. We have 
no specific for the disease, and the treatment is thus 
symptomatic. At the outset, castor oil and calomel 
are given^to overcome the constipation which gener- 
ally exists. For the relief of the nausea and vomit- 



42 FEVERS. 

ing, ice may be swallowed, and morphia subcutaneously 
injected in the epigastric region. 

Hsenisch suggests that transfusion after previous 
bloodletting might paralyze or modify the injurious 
operation of the yellow fever miasm. 

As soon as the stomach is able to retain food and 
drink, a light nutritious diet is essential, with wine 
and quinine and preparations of iron. 

Dengue, Dandy Fever, Breakdown Fever, 

Is unknown in this country, but prevails in America, 
the East and West Indies, and other parts. 

Its cause is not known, but it is believed to be con- 
tagious. 

Symptoms. — After an incubation stage of from 
twenty-four hours to ten days, the patient is suddenly 
attacked with chilliness and weakness, and pains in 
the joints and large bones, as in rheumatic fever, w r ith 
subsequent swelling. Fever is high, and with it there 
is often a red rash like that of scarlatina, but of short 
duration. 

About the third day, a peculiar eruption appears on 
the palms of the hands, rapidly spreading over the 
whole body, and disappearing within twenty-four 
hours. 

Remission of the fever succeeds, but is followed 
by two or three relapses. The average duration of 
the fever is about eight days, but recovery from it is 
tedious, as there is marked debility. It is rarely fatal. 

Treatment. — Emetics and purgatives are recom- 



ERUPTIVE FEVERS. 43 

mended at the outset, followed by saline diaphoretics, 
with opium to allay the pain, and ice locally to relieve 
the headache. 

The diet must be regulated, and stimulants ordered 
if there is depression. Convalescence is assisted by 
the use of quinine and the mineral acids (F. 75). 

The Plague, 

Called by Heberden " the black death," was for- 
merly prevalent throughout Europe, and terribly fatal. 
Xow it is little known except in certain parts of the 
East, Egypt, and Asia Minor. It is caused by a 
morbid poison w T hich spreads by contagion, and is epi- 
demic in its nature. 

Post-mortem appearances reveal great congestion of 
internal organs, especially the spleen, with effusion 
into serous cavities. 

It is characterized during life by fever of a low 
type, with high delirium tending to a typhoid form, 
by enlargement of lymphatic glands and formation of 
buboes, with carbuncles and ecchymoses, vomiting of 
black matter, and haemorrhage from the mouth, stom- 
ach, and bowels. There is often, also, a cutaneous 
rash like that of typhus. 

It terminates most frequently in death. 

ERUPTIVE FEVERS. 

Small-pox, measles, and scarlet fever are simply 
continued fevers with a characteristic eruption super- 
added. In these fevers, a definite period of time 



44 ERUPTIVE FEVERS. 

elapses from the reception of the fever until the ap- 
pearance of the eruption and its final disappearance. 
Thus, measles has an incubation of from twelve to 
fourteen days, the eruption appearing on the third or 
fourth day of the fever, and fading on the seventh. 

Scarlet fever has an incubation of from four to six 
days, the eruption appearing earlier than measles, viz., 
on the second day of the fever, and disappearing on the 
fifth. Small-pox has an incubation of from twelve to 
fourteen days, the eruption appearing on the third day of 
the fever. The eruption does not fade away so rapidly 
as in the other two ; scabs form on the tenth day of the 
fever, and commence to fall off about the fourteenth. 

These fevers are distinguished from one another not 
merely by the facts mentioned, but by other peculiari- 
ties. 

Small-pox. 

In small-pox * a specific poison is taken into the 
system, and after twelve days' incubation fever is 
ushered in with shivering, weariness, and pain in the 
small of the back, and very frequently vomiting. 
These two latter symptoms are very characteristic of 
small-pox, and may guide in distinguishing it, before 
the eruption appears, from the two other fevers men- 
tioned. Sometimes very acute delirium may appear 
in the first twenty-four hours, not remaining over 
three days. In children convulsions are substituted 
for the delirium. Lachrymation and salivation are 
often early symptoms. A papular eruption appears on 
the third day on the forehead, neck and hands, then 



SMALL-POX. 45 

on the trunk, and lastly on the lower extremities. If 
the papules remain separate and distinct, we have 
what is termed simple small-pox, or variola discreta. 
If they are numerous they coalesce, and we have con- 
fluent small-pox, or variola confluens. Just after the 
eruption has made its appearance, the primary fever 
abates or disappears altogether, to be followed by 
the secondary fever, which differs from the primary 
in being of a typhoid, in other cases, inflammatory 
type. 

In variola discreta we observe on the third day a 
vesicle forming on the papulae, and around this an in- 
flamed area. Two days after this, the transparent 
lymph which the vesicle at first contains is changed 
into pus. After this the top becomes gradually de- 
pressed until it divides the pustule into two. This 
condition is termed umbilication, and is very charac- 
teristic of the small-pox eruption. A peculiar odor, 
difficult to describe, but never forgotten if once per- 
ceived, is now apparent in the room. 

About the eighth or ninth day the pustule breaks 
and a scab forms. Generally after ten days from the 
commencement of the fever, or on the eighth day of 
the eruption, the scab falls off, and a red stain is left 
on the skin, which gradually disappears. The second- 
ary fever culminates usually at this time along with 
the eruption. Should, however, the true skin be at- 
tacked, a permanent mark remains, and the patient 
becomes pock-marked. 

In variola confluens the pimple state of matters we 
have described is generally altered for the worse. The 



46 ERUPTIVE FEVERS. 

headache, the pain in the back, and the vomiting are 
more severe, and a more copious eruption appears. 
Developing as the simple type did, the vesicles become 
so continuous as to render it sometimes impossible to 
put a pin's head between them. This is specially ob- 
served in the face, which becomes so swollen as to 
render the features unrecognizable. Large black scabs 
form, and the characteristic odor is sickening in the 
extreme. The mucous membranes of the mouth, 
larynx, and trachea are implicated. The voice is 
husky, throat sore, and swallowing is difficult. Cough 
and dyspnoea are also distressing, and there is 
delirium. 

There is thus a very apparent distinction between 
the general appearance and symptoms of the simple 
and confluent type of small-pox ; and there is also a 
great difference in the intensity of the secondary fever, 
which sets in in both cases on the eighth day of the 
eruption or eleventh of the fever. It is usually slight 
in the first variety, while it is violent in the second, 
and very often proves immediately fatal. It may be 
accompanied by boils, erysipelas, or ulceration of the 
cornea or membrana tympani. 

Prognosis. — In persons who have been previously 
vaccinated efficiently, or in whom the attack is non- 
confluent, the disease is rarely fatal. In those who 
have not been vaccinated the mortality is one in three. 
Further, if the papules be filled with blood (hemor- 
rhagic form of eruption) or serum, not umbilicated, 
and if extending, the prognosis is extremely unfa- 
vorable. Lastly, the " corymbose " form of eruption 



VACCINIA, OR COW-POX. 47 

(where it groups itself into patches) is of very bad 
omen. 

Treatment — Neither vaccination nor medicine is of 
any avail when small-pox is incubating or has ap- 
peared. The disease must run its course, and all that 
can be done is to enable it to do so under the most 
favorable circumstances. The patient should be kept 
in a cool, well-ventilated room. The diet ought to 
be light, and saline draughts or lemon-juice may be 
administered to diminish the thirst and regulate the 
bowels. 

In the secondary fever, if it be severe, stimulants 
should be given, with good broth or strong beef tea. 
If there is great restlessness, opium or bromide of 
potass and chloral do good service. If sores are 
sloughy, and the system is greatly depressed, wine or 
brandy must be administered to sustain the strength 
through the attack. 

Locally no escharotic treatment seems of any avail. 
The pustules should be smeared with cold cream or 
carron oil, or carbolic acid lotion (F. 56a), or with 
oxide of zinc and hydrocyanic acid to relieve the itch- 
ing (F. 61). 

When the pustules have burst, some dry powder or 
starch or oxide of zinc should be applied. 

All scratching should be prevented, and to effect 
this the hands of young patients should be tied. 

Vaccinia, or Cow-pox. 

The remarkable discovery of Jenner towards the 
end of the last century makes an era in medicine. All 



48 ERUPTIVE FEVERS. 

experience testifies that, while vaccination does not 
infallibly prevent small-pox, it yet so far modifies the 
disease as to rob it of its disgusting phenomena and 
sequelae, and to render it a comparatively trifling 
malady. It is unnecessary to detail the process of 
vaccination further than to state that after the simple 
operation has been performed, a little redness and ele- 
vation can be detected on the second day. A vesicle 
with depressed centre and raised edges is seen on the 
fifth, and reaches its acme on the eighth day. It is 
now observed to be composed of a number of cells 
containing clean lymph situated on a hardened base. 
On the ninth or tenth day these burst, and a scab is 
formed which finally falls off on the twenty-first day, 
leaving a well-marked permanent cicatrix. 

A little constitutional disturbance attends the * 



process. 



Varicella, or Chicken-pox, 



Is a trifling affection, attacking infants or young 
children, attended with only slight fever, if with any. 
The eruption consists at first of pimples, which on the 
second day are converted into vesicles. These burst 
on the fourth day, and rapidly dry up. The rash first 
appears on the shoulders or trunk, subsequently it 
may attack the scalp, but it rarely involves the face. 
It seems to have an incubation of four days, and is 
undoubtedly contagious. 



scarlet fever. 49 

Scarlet Fever 

Is eminently contagious. It is usually a disease of 
childhood, occurring once in a lifetime, and it derives 
its name from the character of the eruption, which is 
red, minutely punctated, appearing on the second day 
of the fever or earlier, and lasting three days. It 
commences on the arm£ and trunk and lower side of 
the thighs, and thence proceeds to the face and the 
inferior extremities. In addition to the fever and the 
eruption the disease evidences itself on the tonsils and 
mucous membrane of the mouth and pharynx. 

It varies in severity, and hence has been divided 
into 

Scarlatina simplex, 
" anginosa, 

" maligna. 

In scarlatina simplex the fever runs a simple and 
natural course, the eruption appearing after the usual 
incubatory stage, disappearing on pressure, fading on 
the fifth day, and terminating generally with desqua- 
mation of the cuticle on the face and trunk. This des- 
quamation takes the form of scurf on the body, while 
on the hands and feet large patches of skin may come 
away at once. The process of desquamation may con- 
tinue for days or weeks, accompanied by itching. The 
tongue in scarlet fever is very characteristic. At first 
it may be covered with a white fur; as this clears away 
it becomes red, the lengthened filiform papillae pro- 
ject, and the organ presents a strawberry appearance. 



50 ERUPTIVE FEVERS. 

The tonsils and mucous membrane of the mouth are 
congested, but in a mild degree. 

In scarlatina anginosa the fever is of a much more 
violent character, being often attended with delirium, 
great restlessness, and prostration. The temperature 
often reaches the highest point in the first twenty-four 
hours of the fever. This point varies much, and may, 
although rarely, reach 109° or 110°. The eruption 
may be delayed to the third or fourth day, is of a more 
livid color, and it may be even patchy and evanescent. 
The throat symptoms are more severe, the tonsils being 
greatly swollen, and ulcers frequently forming on them. 
The neck is stiff, the submaxillary glands enlarged, 
and deglutition is difficult. Even after the eruption 
has disappeared, the throat symptoms do not abate in 
severity as in the simple form. 

Scarlatina maligna is attended with marked cere- 
bral disturbance, passing into coma, and with great 
vital prostration. Tenacious phlegm hangs about the 
mouth and throat, the teeth are covered with sordes, 
the tonsil ulceration may become gangrenous, and the 
breath is very offensive. The rash is irregular in its 
appearance and its continuance, and is of a livid color. 
This variety, as its name implies, is usually fatal. 
The vital powers succumb to the strength of the poison 
on the fourth or fifth day. Hope may, however, be 
entertained if the seventh or eighth day is passed. 

The dangers arising from scarlet fever, considered 
as a whole, do not terminate with the subsidence of 
the fever. Troublesome and even fatal sequelae may 
result. The cervical glands may remain permanently 



SCARLET FEVER. 51 

enlarged, abscesses may form, ophthalmia result, or a 
mueo-purulent discharge obstruct the nares, or the 
throat affection may spread from the pharynx up the 
Eustachian tube, causing disease of the ear and deaf- 
ness. One of the most common and not the least 
dangerous sequelae, however, is the affection of the 
kidneys, resulting in anasarca and albuminous urine. 
It is to be carefully observed that this result is most 
common in those cases where the primary fever was 
of a mild form. The patient has probably suffered 
little or no disturbance from the fever, and is perhaps 
exposed to cold or draughts during the stage of des- 
quamation. The excretory powers of the skin are 
impeded, and increased work is thrown on the kid- 
neys, bringing on acute desquamative nephritis (acute 
Bright's disease). This may be ushered in with shiv- 
ering, fever, and pains in the back, or it may come on 
insidiously. The face becomes puffy, and this is fol- 
lowed by general swelling, with scanty, high-colored, 
and albuminous urine. Microscopically, the urine 
presents blood-corpuscles, coagulated fibrin, and epi- 
thelial casts. 

Anatomical Changes. — There are no distinctive post- 
mortem appearances in scarlet fever. The ordinary 
anatomical changes may be summed up in a single 
sentence — erythematous inflammation of the skin, with 
superficial cedema ; inflammation of the fauces, and 
congestion and catarrh of the tubules of the kidneys. 

Prognosis. — The throat is the source of greatest 
danger. " Whenever," says Sir Thomas Watson, " I 
see the glands much enlarged at the angle of the jaw, 



52 ERUPTIVE FEVERS. 

and beneath the jaw, in a child suffering from scarlet 
fever, I augur ill of the disease." If, in addition, the 
urine is very scanty and albuminous, the danger is 
increased by a tendency to uraemia. When these 
symptoms are absent the prognosis is more favorable. 
In the majority of cases the dropsy disappears, though 
serious permanent injury to the kidney may be the 
result. 

Treatment. — Attention to the bowels, with a slight 
febrifuge mixture, and rest in bed, are alone necessary 
in simple scarlet fever. For a drink in this, as in the 
severer forms, potass, chlor., 60 grains in a pint of 
water, may be given freely. The parents should be 
warned to keep the patient in bed in a warm room, 
until the desquamation is over, and after that flannel 
should be worn. A warm bath may be given to bring 
out the eruption. 

In scarlatina anginosa, in addition to the above, if 
the fever is considerable, tepid sponging, cold effusions, 
or wet-sheet packing may be employed. Shaving of 
the head, and the application of vinegar cloths after- 
wards, should be insisted on. If the throat is much 
inflamed, and the patient is an adult, five or six leeches 
should be applied. If a child, hot poultices should 
be applied instead of leeches. 

Beef tea, wine, and ammonia are necessary if the 
patient is weak and prostrated. 

The great prostration in scarlatina maligna necessi- 
tates from the first a stimulating treatment. Wine or 
brandy should be given freely. Three ounces of port 



MEASLES. 53 

wine may be given to a child, and double or treble 
that quantity to an adult, in the twelve hours. 

The ulceration of the throat ought to be touched 
with nitrate of silver, or with a mixture of iron and 
glycerin. Ammonia and bark must also be given 
from the commencement. 

In all cases the body should be rubbed with oil, as 
this facilitates desquamation. Should, however, the 
desquamation be arrested and anasarca result, the loins 
ought to be cupped, and this should be followed by 
the constant application of hot linseed-meal poultices. 

Hydragogue cathartics are also necessary to relieve 
the strain on the kidney, and of these, pulv. jalapse 
co., or elaterium seem the best. Iron, either in the 
form of the tincture or ferr. amnion, cit., should be 
ordered, in as large doses as the system can bear with- 
out producing headache or nausea (F. 89). The diet 
should be generous, with plenty of milk, and a uni- 
form temperature of 60° Fahr. should be insisted on. 
Under such treatment the dropsy may be successfully 
combated, and the albumen disappear from the urine. 

Measles 

AVas long confounded with scarlet fever, and it is only 
since the beginning of the last century that it has been 
recognized as a specific and independent disease. 

Measles is contagious, but the cause of the contagion 
is unknown. Susceptibility to the contagion dimin- 
ishes with years, and second attacks are rare. The 
incubatory stage of measles, judging from the epidemic 

5 



54 ERUPTIVE FEVERS. 

in the Fiji Islands, and other isolated instances, lasts 
from 10 to 12 days. 

Symptoms. — Measles may be considered a catarrhal 
fever, with a characteristic eruption added to it, which 
appears first on the face and forehead, and afterwards 
on the trunk and extremities. The symptoms of 
catarrh — running at the eyes and nose, cough, and 
sneezing, with great oppression and foul tongue — pre- 
cede the eruption. The fever which accompanies these 
catarrhal symptoms indicates that an exanthem will 
follow. This fever, with a temperature it may be of 
102° Fahr., lasts for three or four days, when an erup- 
tion of small circular dots, like fleabites, appears on 
the forehead, spreading to the trunk, limbs, and feet. 
These do not remain distinct, but coalesce until patches 
of a reddish color and of irregular shapes cover the 
parts affected, accompanied by flushing of the face. 
Thirty-six hours from the commencement of the erup- 
tion the temperature is highest. The eruption lasts 
three days, and disappears in the same local sequence 
as it came. 

There are two kinds of measles, — the essentially 
mild and the severe. 

Of the first variety there seem to be two forms — 
measles without catarrh and measles without erup- 
tion. 

The former attacks chiefly young persons, gives rise 
to little sickness, yet effectually destroys the after-sus- 
ceptibility to the disease. 

The latter variety is seen during an epidemic of 
measles, and we are justified in assuming a person to 



MEASLES. 55 

have it if the catarrhal symptoms are as severe as if 
the patient had a measly rash, and if the person be- 
comes non-susceptible to the disease. 

The essentially severe form of measles, popularly 
termed "black measles/' is generally associated with 
the hemorrhagic diathesis. Before or after the erup- 
tion of measles, hemorrhage occurs in various regions ; 
in the skin, causing petechia or ecchymoses ; in mucous 
membranes, causing violent bleedings from the nose, 
or in organs and cavities. 

The general symptoms are those of a typhoid char- 
acter; sordes on the teeth, small pulse, debility, and 
diarrhoea. 

Complications. — Catarrhal pneumonia "and bron- 
chitis — an extension of the catarrh down the respira- 
tory tract — are chiefly to be dreaded in measles. They 
appear after the eruptive stages, and intensify the fever 
and increase the danger. Of fatal augury are livid 
lips, cold extremities, and a rapid feeble pulse. Cere- 
bral complications, peculiar forms of ophthalmia, 
dropsy, and albuminuria are not unknown. 

Prognosis. — As a general rule it may be stated that 
measles is essentially dangerous to very young chil- 
dren, and that the danger decreases rapidly with years, 
except in old age, when it may be fatal. Unusual 
sparseness or paleness of the eruption, or the hemor- 
rhagic diathesis, are bad omens. If the chest is only 
slightly affected, or not at all, we may predict a favor- 
able result. The great danger is not in the disease, 
but in what it leaves behind it, such as lobular con- 



56 ERUPTIVE FEVERS. 

densation or collapse of the lung, or a tendency to 
emphysema in after-life. 

Treatment. — As the greatest danger in measles is an 
extension of the catarrh to the lungs, all exposure to 
cold must be avoided. The room should be darkened 
and the patient kept in bed. Milk diet, attention to 
the bowels, and a slight diaphoretic mixture, are all 
that is required in ordinary cases (F. 34). 

If there is severe coryza, warm water may be drawn 
through the nose. Emetics are useful at the com- 
mencement to prevent cough, and cold compresses may 
be applied to the abdomen if diarrhoea is excessive. 
Should chest complications ensue, the principles of 
treatment to be afterwards spoken of under acute bron- 
chitis should be adopted. Trousseau has recommended 
whipping the whole skin with nettles. 

In the typhoid state associated with the hemor- 
rhagic diathesis, wine and stimulating expectorants 
are essential (F. 72). 

Rubeola, Rotheln (German Measles). 

The term rubeola was brought into use by German 
physicians about the middle of the last century to 
characterize a disease which it was considered could 
belong to no one of the acute contagious or non-con- 
tagious eruptions, though closely resembling measles 
and scarlet fever. 

Opinions with regard to it have greatly varied, but 
latterly it has been shown that it is an independent 
disease by distinct epidemics of it, and by the fact 



RUBEOLA. 57 

that while it insures against a second attack of itself, 
it affords no protection from measles or scarlet fever. 

Recognizing it therefore as a contagious and essen- 
tially epidemic, and thus also specific disease, it may 
also be noted that it is especially a disease of child- 
hood, attacking indiscriminately boys and girls, and 
older and younger children down to sucklings. A 
second attack is rare — as rare as that of measles. Its 
contagion is not quite so great as that of measles. 

It consists of an eruption on the skin of numerous 
discrete blotches, from the size of a pin's head to, at 
the utmost, that of a bean, slightly raised above the 
level of the skin, with at times a distinct, at others a 
faded border. 

The spots are round or oval, and are Avell marked 
on the face, their color being of a pale rose-red. They 
are seen on other parts of the body, especially on the 
neck, scalp, and thighs ; while on the forearms, hands, 
and lower parts of the legs they are not so common. 

The eruption lasts usually for two days, and then 
disappears without any desquamation. The size of the 
spots is less than that of measles, the form being more 
round and the color paler. 

Symjitoms. — The course of the disease in the ma- 
jority of cases is as follows : After the patients have 
coughed and sneezed somewhat, and manifested slight 
photophobia, from a few hours to a day, one notices — 
either at once or after the attention has been excited 
by a gradually increasing temperature — the beginning 
of the exanthem on the face. While now the exan- 
them gradually spreads over the body, the tempera- 



58 GENERAL DISEASES. 

ture, if increased, becomes quickly normal again. 
Thus children generally object to stay in bed, and 
would prefer to be out of doors. 

In ordinary rubeola there are no other local symp- 
toms except slight catarrh at times, some difficulty 
in swallowing, and some diminution of appetite. 

Prognosis. — Its almost feverless course makes the 
prognosis most favorable, but the disease may be com- 
plicated with bronchitis, and may have a fatal termi- 
nation. 

Treatment. — The treatment of rubeola is restricted 
to a suitable regimen ; protection against exposure, 
keeping the patient in bed if feverish, and attending 
to probable catarrh of the air-passages and the 
pharynx. 

Other complications, if any, should be treated ac- 
cording to their nature. 



Dropsy. 

By dropsy is meant a collection of serous fluid in 
one or more of the shut cavities of the body, or in 
the meshes of the areolar tissue, or in both. Dropsy 
is not so much a disease per se as it is symptomatic 
of other diseases. And it may be viewed in two 
aspects : first, as to its cause — the organ implicated ; 
second, with regard to the dropsical eifusion. Differ- 
ent terms have been given to the effusion in relation 
to its different sites. 



DROPSY. 59 

Hydrocephalus is the term applied when the effu- 
sion is in the ventricles of the brain, or in the sub- 
arachnoid space. 

When in the pericardium, hydropericardium. 
" " pleura, hydrothorax. 
" " peritoneal cavity, ascites. 

When it is situated more or less generally in the 
subcutaneous areolar tissue all over the body, it is 
termed anasarca ; when it is confined to one particular 
part of the areolar tissue, the term oedema is used. 

To account for dropsy, it is to be remembered that 
all closed cavities and interstitial tissues are kept 
moist during life, by a continual serous exhalation 
from these surfaces, wmich exhalation again is as con- 
tinually and constantly absorbed. When dropsy 
occurs the balance has been destroyed. There is either 
too much exhalation, an increase of fluid sent out, or 
absorption is impaired, while the exhalation continues 
the same. 

Dropsy is thus naturally divided as arising from 
defective absorption — chronic or passive dropsy; or 
excessive exhalation — active or acute. Similarly any 
interruption to the venous return, by favoring exuda- 
tion, originates dropsy. 

Although anything which tends to weaken the sys- 
tem and impoverish the blood, such as bad or insuffi- 
cient nourishment, or exhausting disease, may cause 
dropsy, yet there are three great kinds of dropsy, 
which are named after the organs implicated, cardiac, 
renal, or hepatic. 



60 GENERAL DISEASES. 

Cardiac dropsy, due to disease of the heart, com- 
mences in the feet and hands, and mounts upwards, 
ultimately becoming diffused all over the body. 

Renal dropsy originates in the face and upper ex- 
tremities, and is frequently first observed in the loose 
cellular tissue about the eyelids, ultimately affecting 
the feet and serous membranes. 

Hepatic dropsy is localized at first, being confined 
to the peritoneal cavity. The portal system of veins 
is alone implicated, and hence the legs, feet, and hands 
may not give evidence of dropsy for some time. 

Dropsy in the subcutaneous areolar tissue is easily 
recognized. There is swelling; the skin is pale, and 
may be tense and glazed. There is no actual pain or 
tenderness, but simply a feeling of uneasiness and dis- 
comfort. Pressure on the skin causes what is termed 
"pitting," and this is due to its want of elasticity. 
The diagnosis of ascites, L e., the accumulation of fluid 
in the peritoneal cavity, is more difficult. That fluid 
is present is recognized by the fact that the abdomen 
is swollen, and that the liquid is free is shown by the 
ease with which it goes from side to side on varying 
the position of the patient; and further, on placing 
the hand on one side of the abdomen, and striking on 
the opposite side with the other, the wave of the fluid 
communicates a perceptible sensation. 

Ascites may be confounded with tympanitis, but 
the distinction between them is, that tympanitis gives 
an exaggerated sound to percussion all over the ab- 
domen ; whereas in ascites the centre is clear, but the 
gravitation of the fluid renders the flanks dull. To 



DROPSY. 61 

distinguish it from distension of the bladder and from 
pregnancy, the history of the case, and the application 
of the catheter in the one instance, and the stethoscope 
in the other, are sufficient. 

The history of the swelling commencing on one 
side, and the facts that this swelling does not shift 
with the different positions of the patient, and that 
the sound on percussion is dull and deeply seated, in- 
dicate the presence of an abdominal tumor, which is 
confirmed by examination, showing that neither heart, 
kidney, nor liver is at fault. 

Dropsical fluid presents the following characters : 
It is thin and watery, generally of a pale straw color, 
and having a specific gravity of 1008 to 1014. Its 
reaction is usually alkaline. It is allied to blood 
serum in this, that it holds in solution albumen and 
alkaline and earthy salts, especially the chlorides. 
The proportion of solids is, however, much less, and 
the albumen, especially, varies in quantity. 

Treatment. — Without entering specially into the 
treatment of the different kinds of dropsy, it is to be 
observed that there are obvious indications — 

1. To remove the fluid; 2. If possible to prevent 
its recurrence ; and, if neither the one nor the other 
is possible, palliative measures are necessary. 

Rest in the recumbent posture is of paramount im- 
portance, and the part in which is the greatest effu- 
sion must be elevated and supported. For this end 
raise the anasarcous limb, and support the scrotum. 

There are three great channels for getting rid of 
the effusion — the skin, the kidneys, and the intestines ; 

6 



62 GENERAL DISEASES. 

and if the remedies employed to eliminate it by these 
organs fail, then tapping or puncturing must be had 
recourse to (F. 33, 37a, 27). 

Tuberculosis. 

The term tuberculosis means a certain peculiar con- 
dition of the system, most probably originating in the 
blood, and showing itself in such conditions as scrofula, 
pulmonary consumption, tubercular hydrocephalus, 
tabes mesenterica, etc. We are ignorant of what 
change the blood undergoes; yet, we are justified in 
stating that it is a deficiency of red corpuscles, and an 
increase of the watery portion. In some towns, 35 
per cent, of the death-rate is due to the tubercular 
diathesis, and all over the country it is the cause of 
the direct mortality of one-seventh of the classified 
forms of disease. 

Authorities seem to agree that the morbid state of 
the blood gives rise to the specific production of tu- 
bercle. After the admission of this fact, there are 
three widely different views of the subject. 

One is, that the liquor sanguinis is exuded from 
the capillaries, as in ordinary inflammation, and that 
this exudation, instead of forming pus, is, owing to 
the peculiar state of the system, transformed into 
tubercle. 

Another is, that while there may be an exudation, 
this is not the whole, but the minor part of the pro- 
cess, for the cells of the lung-tissue tend to increase 



TUBERCULOSIS. 63 

for some time, then they shrivel up and die, thus con- 
stituting tubercle. 

A third view is that tubercle is the product of in- 
fectious disease — this infectious disease being due to 
the absorption of cheesy morbid products into the 
blood, which, in some peculiar manner, act as a 
specific inflammation in the production of tubercle. 
Some modify this opinion by saying that the caseous 
matter produces tubercle by a local influence, through 
the lymphatics, and not by general infection. 

There are two forms of tubercle — the gray and the 
yellow; the former consisting of minute, firm, bluish- 
gray granules, about the size of a millet-seed; hence 
the term miliary. Sometimes, however, they are as 
large as a small pea. They are generally firm, and of 
a semi-cartilaginous hardness. 

Yellow tubercle is not semi-transparent, but opaque, 
its color varying from a dirty white to a bright ap- 
pearance. It has been likened to cheese; and as the 
consistence of cheese is not uniform, in some cases 
being firm and tough, in others creamy and easily cut, 
so the yellow tubercle is firm and tough, or fluid and 
soft. This tubercle may be found alone in isolated 
masses, or a large portion of the lung may be infil- 
trated with it, or the large masses may tend to crowd 
together, resulting in the formation of cavities. 

We shall not enter further into the question of gray 

as distinguished from yellow tubercle, except to note 

that microscopically they are the same, and chemically 

they present no point of difference, consisting in both 

- of animal matter and earthy salts, and having 



64 GENERAL DISEASES. 

the appearance of a group of round cells, with one or 
more giant cells in centre, obscured by products of 
inflammation. 

What becomes of tubercle thus deposited or formed 
in the lung? 

It may be absorbed, or it may be converted into a 
cheesy consistence by means of fatty degeneration, 
which again may become hardened, undergoing the 
change termed calcification. Bringing these points to 
a practical issue, it is to be observed, in regard to a 
cavity in the lungs, that, the matter being coughed up, 
the ulcerated walls may fall together and adhere, or 
they may become lined with a false membrane, and 
a chronic cavity may be the result. To establish the 
cure it is necessary that the blood should become so 
healthy as to prevent the deposition of further tuber- 
cle, or of what may become tubercle. 

It is impossible to deny that tuberculosis is heredi- 
tary, and that it may also originate from breathing a 
vitiated air, or from want of proper nourishment or 
exercise. Any disease which tends to weaken the 
body and impair digestion favors the development of 
tubercle; and it may be further added that, whenever 
an organ is specially weakened by previous disease, 
there tubercle may form. It may also be stated that 
general tuberculosis has been set up in animals by the 
inoculation of caseous material. 

What general symptoms indicate tubercle? 

A delicate white skin, which at times blushes with 
a rosy hue of characteristic beauty; a coldness of the 
body ; in youth great precocity both in walking and 



TUBERCULOSIS. 65 

talking ; a somewhat swollen abdomen ; and a strong 
disinclination for all fatty food. 

When the tubercles are forming, or have actually 
formed, there is marked debility, loss of flesh, and a 
fever of a remittent character, as is indicated by a rise 
of the thermometer in the evening and a fall in the 
morning. 

The scrofulous diathesis cannot be considered to be 
distinct from the tuberculous. It is simply a coarser 
expression of the same picture. The lymphatic glands 
of the neck are enlarged, sometimes even they sup- 
purate; the face is not so intelligent, nor has it the 
same transparency or regularity of feature ; the lips 
are frequently thick and swollen; the nose flattened ; 
forehead low; the teeth carious; and the belly much 
enlarged during early life. 

Mr. Paget says: "The scrofulous constitution is 
peculiarly liable to tuberculous disease." 

This tubercular diathesis may be mistaken in early 
life for typhoid fever. The indications by the ther- 
mometer are similar; but there is an absence of gur- 
gling in the iliac region, of rose-colored spots, or of 
characteristic pea-soup stools ; and while night-sweats 
are associated with tuberculosis, they are unknown in 
typhoid fever. 

Tubercular disease is often preceded by what is 
called strumous dyspepsia. By that term is not meant 
ordinary dyspepsia, pain or vomiting after taking food, 
but a kind of shuddering distaste for all fatty food, 
and which, if taken, gives rise to nasty acid eructa- 
tions quite distinct from ordinary faulty digestion. 



66 GENERAL DISEASES. 

. 

Statistics show that this dyspepsia was present in 77 
per cent.; and out of 50 cases carefully tabulated by 
Mr. Hutchinson, it was found that it had preceded the 
chest symptoms in 33. 

Prophylactic measures are necessary to prevent the 
transmission of tubercular disease. 1st. Marriage 
should be well assorted, and should not be contracted 
by those laboring under this diathesis. 2d. If a child 
is born when there is evidence of this complaint on 
the part of one or other of the parents, it should be 
intrusted to a healthy wetnurse, and should be much 
in the open air both daring and after lactation. 
Cleanliness and friction of the skin should be attended 
to ; and substances which are likely to occasion diar- 
rhoea, such as fruits and pastry, should be avoided. 

If circumstances permit, such children should be 
sent to a warm and equable climate until the consti- 
tution is well developed. They will there be enabled 
to spend much time out of doors without risk of catch- 
ing cold, and thus obtain the most important hygienic 
factors — daily exercise and a pure atmosphere. 

On the same principle sea voyages are useful. 
There is not much risk of catching cold at sea, and 
the appetite and the digestion are improved. 

The appropriate treatment for each of the tubercu- 
lar complaints — phthisis, tabes mesenterica, etc., will 
be alluded to under the separate diseases. The gen- 
eral principles, however, are good nourishment, fresh 
air, warm clothing, .and great attention paid to the 
digestive system. By these means, aided by appro- 



SYPHILIS. 67 

priate medicines, it is our hope to remedy the blood 
disease connected with tuberculosis (F. 81). 

Syphilis. 

Syphilis is a chronic infectious disease with different 
symptoms at different stages of the malady. As a 
separate and distinct disease, syphilis dates from the 
end of the fifteenth century, when a notorious epidemic 
of it occurred in Italy, which gradually became less 
malignant, and the physicians then inferred, falsely, 
as we now know, that it would wear itself out, and 
cease altogether to infect the human body. The dis- 
ease is at the present day prevalent throughout the 
world, although its principal sites, for obvious reasons, 
are large seaport towns and great commercial centres. 

The most common way by which syphilis can be 
communicated is by the genitals as the result of 
sexual connection. A little red papule appears, fol- 
lowed by hardness and induration. A few days after 
this the lymphatics of the groin are enlarged, become 
hard to the touch, without tenderness, and freely mov- 
able beneath the skin. Shortly after the affection of 
the lymphatics, the papule is seen to be scaly or 
covered with a thin crust, which, when removed, dis- 
closes a shining surface of a bright red color with a 
scanty secretion. Meanwhile, the patient begins to 
feel weak and somewhat indisposed, and in the course 
of from six to eight weeks from the appearance of the 
papule, an eruption is observed on the skin of a red 
color and unattended with itching. 



68 GENERAL DISEASES. 

This is the commencement of constitutional syphilis. 
Simultaneously with the red eruption, or shortly after- 
wards, the throat begins to be inflamed; the inflam- 
mation leading to ulceration or to the production of 
circumscribed flat growths on the mucous membrane. 
There are frequently also more or less baldness, affec- 
tions of the nails, pains in the bones, inflammations of 
the iris, or of the deeper structures of the eye. 

Now the disease properly treated may take a favor- 
able course, with disappearance of the symptoms and 
restoration to health in from ten to twelve months 
from the time of affection. But in the majority of 
cases new crops of eruptions come and go on the skin 
and mucous membranes ; and thus we have small 
papules on the tongue, and scaly isolated patches of 
psoriasis on the palms of the hands or other parts of 
the body. If the constitution is weak and scrofulous, 
eruptions tending to suppurate may be developed. 
These become incrusted and form ulcers, which finally 
heal by cicatrization. 

Severe ulcerations may also be developed in the 
throat and nasal cavities, in which latter the bones 
may be laid bare and the nose become permanently 
depressed. Tumors may form in various internal 
organs, especially the liver, the testicles, and the brain; 
and, unlike tumors of a purely inflammatory charac- 
ter, they do not shrink up after the inflammation is 
over, but, from being hard, soften into a kind of 
gummy semifluid consistence; hence they are termed 
gummy tumors or gummata. Phthisis may now be 



SYPHILIS. 69 

set up, with albuminuria and dropsy due to amyloid 
degeneration of the kidneys. 

Constitutional syphilis may also be communicated 
from local secondary lesions, as by kissing, etc., by 
syphilitic nurses, by vaccination when blood is taken 
along with the lymph of the vaccine vesicle, etc. 

The syphilitic cutaneous affections may be of various 
kinds; probably the squamous variety is the most 
common, appearing in patches of a coppery color, 
and having the scurf renewed as fast as it is shed. 

Treatment. — It is doubtful if the initial lesion can 
be destroyed at the seat of infection, opinions varying 
on this important point. Experience testifies that all 
treatment of constitutional syphilis is futile without 
the aid of mercury. How this remedy acts we cannot 
tell. There are three modes of employing it : 

1. By inunction; rubbing in some ungt. hydrarg. 
every night, after washing the part with soap and 
water, and stopping the remedy whenever the mouth 
becomes in the slightest degree affected. 

2. By fumigation ; 8, 15, to 20 grains of calomel 
being employed for this purpose. The patient, un- 
dressed and enveloped in a blanket, being seated on 
an ordinary cane-bottomed chair, the calomel, placed 
on a small metal vessel below which the spirit-lamp 
is burning, is evaporated in about 15 minutes and de- 
posited on the skin of the patient. This method may 
likewise be continued daily, until slight mercurializa- 
tion is produced. 

3. By mercurial preparations internally, that one 
being chosen which can be continued for the greatest 



70 GENERAL DISEASE'S. 

length of time without producing digestive derange- 
ments. 

Thus pil. hydrarg. is good, or hydrarg. cum creta, 
or the perchloride in the form of a pill, or in a mixture 
in doses of y^ of a grain. Thus, 

IJ. Hydrarg. Perchlor., . . gr ij. 

Ext. Gent., . . . . gr. xxx. M. 

Divide into xxiv pills, one thrice daily; or (F. 1), 
(F. 3), thrice daily. Iodide of potassium may be 
given alone for a considerable time afterwards. This 
remedy is specially serviceable in affections of the 
bones and pustular eruptions. If there is much 
anaemia, it may be combined w T ith carbonate of am- 
monia or ammonio-citrate of iron. Condylomata are 
best treated locally by dusting calomel over them. 

The patient should avoid sudden changes of tem- 
perature, go to bed early, and wear flannel. Beer and 
w 7 ine may be allowed, but no spirits. The teeth should 
be brushed daily with tincture of myrrh or chlorate 
of potass. The diet should be nourishing. 

Eheumatism. 

The word rheumatism is derived from psu/ia, a fluxion, 
and it arises from some disordered or abnormal con- 
dition of the blood. Its frequency has attracted the 
attention of physicians both in ancient and modern 
times, and much speculation has been excited as to 
what causes operate in determining its predisposition 
for the white fibrous tissue, which enters into the 
composition of sheaths, fascia, fibro-serous membranes, 



RHEUMATISM. 71 

and ligaments, and thus in particular affecting the 
joints. The heart and its coverings, moreover, are 
often implicated. 

It is believed that the poison circulating in the 
blood is lactic acid. Dr. Prout first pointed out that 
the blood contained a superabundance of this acid; 
and Dr. Richardson's experiments indicate that the 
injection of a solution of seven drachms of lactic acid 
to two ounces of water into the peritoneum of a cat 
induces not peritoneal but endocardial inflammation 
(especially of the left side of the heart), and fibrous 
deposits on the mitral and aortic valves. The lactic 
acid is supposed to be formed in the pulmonary cir- 
cuit of the blood, and from thence carried into the 
left ventricle, to be propagated by the general circula- 
tion to the parts where the disease is manifested. 

The fibrin appears to preponderate over the saline 
elements of the blood during the disease. Few op- 
portunities have been afforded of examining the state 
of the parts affected when the attack is acute, as few 
people die of rheumatism per se; hence the somewhat 
contradictory statements of different authors. 

Rheumatism is most conveniently divided into 
acute and chronic. In the former, the general and 
local symptoms are well marked. There is usually a 
feeling of coldness, want of appetite, thirst, and more 
or less feverishness attendant on or caused by exposure 
to cold or wet. Pain is experienced in one or more 
joints, and is followed by inability to move, and by 
swelling and great tenderness. The large joints are 
often implicated, but the disease usually attacks the 



72 GENERAL DISEASES. 

middle-sized ones. Hence the knee, ankle, wrist, and 
elbows are the chief seats. The disease tends to shift 
from one joint to another, and does not often remain 
fixed in the one first affected. 

When the disease is thoroughly established, the 
pain is severe, and is intensified by the slightest 
movement. The pulse is full and quick, and the 
fever is attended with a peculiar acrid, copious, and 
sour-smelling sweat. This sweat seems neither to 
mitigate the fever nor relieve the pain. The bowels 
are constipated, and the urine is high-colored, scanty, 
and deposits a quantity of urates on cooling. 

Unfortunately the disease is not limited to the 
joints. It has been found that in three cases out of 
four of acute articular rheumatism with high fever, 
the heart is affected by endocarditis or endopericarditis, 
and the foundation is laid for permanent chronic valv- 
ular disease. The cardiac complication is insidious, 
and frequently attended with no pain, and it is only 
discovered on examination with the stethoscope. 
While pneumonia is rare, pleurisy with effusion may 
complicate matters. 

The temperature ranges from 100° to 104°, gradu- 
ally ascending for at least a week, and subject to con- 
siderable variations. Sometimes it reaches as high as 
108° or 109°, and then death quickly ensues. 

The duration of the attack varies from three to six 
weeks. Relapses are common, and although five to 
six weeks is the usual limit, the attack may extend 
over some months, as it has no fixed epoch for its de- 
parture. The termination is generally in recovery, 



RHEUMATISM. 73 

but often the joint or joints may be left stiff, or may 
become chronically enlarged. The average number 
of deaths is usually 1 in 1000. Rheumatism is not 
thus so serious in itself as in the after-mischief which 
it entails by cardiac and other complications. 

Treatment. — The varying course and duration of 
the disease has clouded the actual value of medicinal 
agents, and hence a shifting therapeutics has charac- 
terized the treatment of acute articular rheumatism. 
Bleeding, mercury, and purgatives have had their 
day, but these are now practically abandoned, and at 
the present time the alkaline treatment is generally 
adopted. It is said that the heart is only implicated 
during the first week of the disease, when the fever is 
high and the urine acid, and that it is not attacked 
when the urine is alkaline. Hence two scruples of 
the bicarbonate of potass and soda should be given 
every three or four hours in half a bottle of soda-water, 
or in effervescing citrate of ammonia or potash draught, 
and should be continued steadily until the febrile dis- 
turbance is much lessened, the pulse reduced, and 
the urine rendered alkaline. If the patient is robust 
and the urine loaded with lithates, ten minims of vin. 
colch. should be added to each draught. 

Locally, alkaline lotions should also be applied. 
Half an ounce of carbonate of soda, and six drachms 
of liq. opii are put into nine ounces of hot water. 
Flannels are soaked in this, wrung out, and applied to 
the affected joints, while gutta-percha tissue is placed 
over all. A sort of local vapor-bath is thus estab- 
lished. 



74 GENERAL DISEASES. 

Lemon-juice may be given as a drink, to the extent 
of two or three ounces daily. 

The patient should always lie between blankets. 
The perspiration is thus absorbed, and there is greater 
comfort, and less risk of catching cold. Milk slops 
and farinaceous food should be the diet at first, fol- 
lowed by beef tea and stimulants, if there be any signs 
of depression, sherry taken with soda-water being, by 
preference, the best stimulant. 

Undoubtedly, since the above was written, in 1876, 
salicin, in fifteen-grain doses every two hours, as rec- 
ommended by Dr. Maclagan, has established a thera- 
peutic era in the treatment of acute rheumatism. Like 
others, I can speak unhesitatingly of the benefits de- 
rived from its adoption, in lowering the temperature 
and diminishing the length of the disease, and also 
from the employment of salicylic acid, when the ex- 
pense of salicin becomes a matter of consideration, as 
it often does in the case of hospital or poor patients 
(F. 87, 88). 

Gout. 

Sydenham, the father of English medicine, was 
himself a martyr to gout, and thus congratulates him- 
self on the fact : 

" So have lived, and so have died, great kings, and 
leaders of armies and fleets, philosophers, and men of 
varied culture, of this peculiar disease. It kills more 
rich men than poor, more wise than simple." 

Gout was formerly considered to be a catarrh, and 
derived its name from the French goute, Latin gutta, 



GOUT. 75 

a drop, because it was supposed to be produced by a 
liquid which was distilled drop by drop into the dis- 
eased part. It is now deemed a specific inflammation, 
attacking by preference those who live well, and es- 
pecially those who are hereditarily predisposed to it. 
It is not unknown in London hospitals, as boatmen, 
butchers, and footmen are admitted with it. In Scotch 
infirmaries it is never seen. 

It rarely attacks women. It is hereditary, and the 
result of living high, and eating too much, and of 
sedentary habits. It is specially induced by port wine, 
strong ale and porter, and rich food, and is rarely due 
to drinking gin or whisky. 

Its special seat is the great toe, but it has also been 
observed on the heel, the calf of the leg, the ankle, 
knee, wrist, thumb, and fingers. 

Symptoms. — An attack of gout is said to come on 
most frequently towards the close of January or be- 
ginning of February. For some days the patient feels 
ill, and out of sorts, with bad digestion, crudities of 
the stomach, flatulency, and heaviness. The temper 
is peevish and irritable. With or without these pre- 
liminary dyspeptic symptoms, the patient may go to 
bed at the usual hour, and awake to find himself suf- 
fering from the most severe and excruciating pain in 
the ball of the big toe, which is said to be similar " to 
dogs gnawing at a bone from which they have already 
eaten all that could be got." Even the weight of the 
bedclothes is oppressive, and no change of posture 
gives relief. After some hours the pain may abate, 
and the patient falls asleep, but on awakening he finds 



76 GENERAL DISEASES. 

the joint inflamed and swollen. There is also fever 
and furred tongue, with great irritability and depres- 
sion. The urine is high-colored, acid, and deficient 
in quantity. It is also loaded with urates and uric 
acid. 

The pain continues, with paroxysms of acuteness, 
for two or three days, in a first and an acute seizure ; 
in other cases, and when the attack is not primary, it 
may last as many months. 

After the paroxysms have subsided, the urine is 
usually copious, with increase of uric acid, which, 
with phosphoric acid, is at first insufficiently elimi- 
nated. 

A violent itching of the toe sometimes precedes the 
attack, or it may sometimes attack the toe when the 
gout is disappearing, followed by decrease of the swell- 
ing and desquamation of the cuticle. 

Gout does not terminate with one attack, though 
after a first seizure some years may elapse before a 
second occurs. The intervals between the attacks be- 
come shorter and shorter, and the patient becomes a 
martyr to gout, which is now not confined to one joint, 
but invades both hands and feet, external ear, eyelids, 
and nose. Deposits of a chalky consistence, called 
tophi, are formed round the joints, these deposits con- 
sisting of urate of soda. Chronic gout is the term 
usually applied to this stage. Occasionally there is 
great distortion of the joints, and sometimes ulcer- 
ation, with discharge of the concretions. 

The same salt also invades the kidneys, being de- 
posited first within the tubules, and subsequently in 



GOUT. 77 

the intertubular tissue, leading to contraction and in- 
duration, and constituting what has been termed the 
gouty kidney. 

Gout at times attacks internal organs, and then it 
is best termed retrocedent gout. A French author 
says : " Articular gout is a disease, internal gout is 
death." It may thus retrocede to the stomach, giving 
rise to vomiting, internal pain, spasm ; or to the heart, 
leading to disturbed action, small feeble pulse, or coma ; 
or to the brain, causing severe headache, sluggishness, 
apoplexy, or paralysis ; or to the lungs, originating a 
form of asthma, with severe cough. 

Dr. Gairdner has alluded to what is termed a gouty 
diathesis. By this is meant a habit of body, in which, 
without gout showing itself externally, flying pains 
are prevalent over the body, which are sometimes con- 
sidered neuralgic, and treated accordingly, whereas 
they are of a gouty nature, and can only be cured by 
colchicum and remedies serviceable in gout. 

Dr. Garrod's researches indicate that, while uric 
acid can be detected as a mere trace in the btood in 
health, in gout it exists in a much greater quantity, 
in fact in detectable excess, as the urate of soda. Re- 
cent investigations seem to indicate that, so long as 
the kidneys are able to carry away this excess, health 
may be maintained. If, on the other hand, the urin- 
iferous tubules become plugged up by deposits of 
urates within them, the urates accumulate in the blood, 
and becoming deposited in a joint or in joints, they 
lead to a .fit of the gout. Should these deposits be 
washed away, the attack is over, and health is regained. 

7 



78 GENERAL DISEASES. 

If this does not take place, the kidneys become atro- 
phied, and chronic gout is the result. 

Diagnosis. — Gout is allied in some measure to rheu- 
matism in its symptoms and pathology, yet differs 
materially from it. Gout attacks either one joint or 
the small joints, and usually occurs after thirty as the 
result of hereditary taint or high living. It is asso- 
ciated at first with a vivid redness, and afterwards 
with the formation of chalkstones ; while rheumatism 
invades the large joints, produces fluctuation there, 
occurs at any age, and is accompanied by fever and a 
peculiar sour-smelling sweat. Finally, rheumatism is 
a disease of the poor, gout of the rich, or of those who 
are able to afford the luxuries of the wealthy. 

In gout, before and during the fit, the urates are 
deficient, though they become excessive afterwards; 
while in rheumatism the urates are always abundant. 

Treatment resolves itself into what to do, and what 
not to do. Cold applied to the foot has been known 
to result in death or hemiplegia. Leeches are rarely 
productive of good, while general bloodletting is now 
abandoned. 

The indications of treatment resolve themselves 
into a brisk purgative of calomel and colocynth', fol- 
lowed by a black draught. When the bowels have 
been freely opened, but not till then, administer col- 
chicum in 10 or 15 TT£ doses every six or eight hours, 
with sedatives and alkalies, or in Vichy water (F. 68). 

Locally, enjoin perfect rest. Wrap the affected part 
in flannel, or cotton-wool, or oiled silk, or apply a 
poultice sprinkled with opium or belladonna, and, 



SCURVY. 79 

when the inflammation has subsided, bandage, and use 
slight friction. During the height of the fever the 
diet should be light and sloppy — milk, arrowroot, tea. 
When the fever abates, give beef tea or chicken soup, 
with plenty of lithia water. For retrocedent gout 
sinapisms and antispasmodics are necessary. 

After the acute attack is over, regulate the digestive 
organs and bowels, and tell the patient to abstain from 
port, heavy sherry, fruit, ale, and porter. Claret and 
hock seem to do good rather than harm. The diet 
should not contain too much animal food, and plenty 
of exercise should be enjoined. 

The mineral waters of Bath, Cheltenham, and Lea- 
mington in this country are beneficial. Those of 
Wiesbaden, Vichy, Carlsbad, and Aix-la-Chapelle, on 
the continent, can be highly recommended. 

Scukvy. 

Scurvy is a disease of great antiquity. It is alluded 
to by Pliny, and at different times it has proved very 
fatal both by land and sea. It is essentially depend- 
ent on the want of fresh vegetables as an article of 
diet, and although it has frequently occurred on land, 
it is pre-eminently a sailor's disease. Other causes 
than that mentioned may predispose to the disease, 
such as great privation, bad food, a marshy soil, and 
defective hygienic conditions ; but these by themselves 
will not specially originate it. That which produces 
scurvy is essentially the want of a vegetable diet. 

While thus aware of the cause of scurvy and the 



80 GENERAL DISEASES. 

means of preventing it, we are ignorant of the exact 
changes which it originates in the system. Different 
statements have been recorded by different observers. 
The blood seems to undergo some change. Older 
writers stated that the blood deposited a black, muddy 
sediment, subsiding from a reddish serum. Later 
writers explain the thickened crassamentum by stat- 
ing that the cohesive power of the fibrin is so much 
lessened as to prevent its being separated from the 
red corpuscles, and that this probably explains the 
meaning of the terms, so often mentioned, " aggluti- 
nated blood " and " thickened crassamentum." Dr. 
Garrod views scurvy as essentially due to the want of 
potash salts in the blood, through the food being de- 
ficient in them. 

The symptoms of scurvy are well marked. They 
come on gradually with weakness, anxiety, bad breath, 
a sallow muddy complexion, and the appearance of 
blotches on the legs. Some pains of a wandering 
character are felt all over the body, while the tem- 
perature is lower than normal, an evidence of deficient 
vitality. 

As the disease advances, the gums become swollen 
and spongy, bleed on being touched, and are said to 
present an appearance similar to that seen when a 
patient is salivated. As the disease reaches an ad- 
vanced stage, the teeth rot from the socket, and haemor- 
rhage takes place from the mouth, nose, stomach and 
intestines. Thedebility becomes extreme,and petechia, 
developing into ulcers or ecchymoses, form on the 
lower extremities. 



SCURVY. 81 

A friend who was much exposed to Arctic privation, 
and who was surgeon to a ship when a fatal attack 
of scurvy broke out, thus describes the disease : 

"The men were listless and dispirited before there 
were positive indications of scurvy. They could 
scarcely drag their legs along, and were unable to go 
aloft, or, if they did so, this was attended with great 
pain and marked debility. The pain seemed rheu- 
matic in its character, and was always worst at night. 
The countenance was sallow and muddy long before 
actual manifestation of the disease. The pain was at 
first confined to the extremities, and upon these the 
effusion of blood first occurred, generally in the form 
of small petechia, which afterwards developed into 
vibices, and sometimes into ecchymoses. A bruise, a 
rebound from a rope, or any small injury, occasioned 
a steady development of an ulcer. Sometimes there 
was extensive and diffused infiltration beneath the 
subcutaneous and intermuscular areolar tissue. 

"The limbs, especially the calves of the legs, then 
became as hard as a board, while above the induration 
the skin w r as either immovable and unaltered in color, 
or had blood suffused under it. 

" When a fatal termination ensued, it either did so 
from extreme exhaustion or general dropsy, unless the 
patient was cut off at an earlier stage by pleurisy, peri- 
carditis, or profuse bloody diarrhoea/' 

Treatment. — From the description of the disease, 
and its cause, there are certain obvious indications 
for treatment. Rest is necessary, and the low vitality 
of the patient requires this rest to be in a warmatmos- 



82 GENERAL DISEASES. 

phere. Antiscorbutics should be administered, such 
as potatoes, lime-juice, oranges, or the freshly squeezed 
out juice of watercresses, mustard, horseradish. The 
extract of these latter plants is useless. 

The diet should consist at first of soups and milk ; 
afterwards, when the digestion has improved, fresh 
meat and vegetables should be given. 

As a local treatment for ecchymoses and infiltra- 
tions, lotions and compresses of aromatic vinegar and 
spirits of camphor have a high reputation. 

Dr. Garrod's theory indicates the administration of 
the tartrate or chlorate of potash, to prevent or cure 
the disease. The barm of beer has also a high repu- 
tation, and of this six or eight ounces may be taken 
daily as an antiscorbutic. 

Purpura 

Seems to be dependent on a lowered vitality, the 
result of liver disease, affection of the spleen, syphilis, 
poverty, intemperance, or overwork. This lowered 
vitality in some way affects the blood, breaking up the 
red corpuscles, and allowing their contents to transude 
into the tissues. 

The blood thus passed through the capillaries is seen 
as circular spots, from the size of a pin's head to that 
of a pea, being apparent first on the legs, afterwards 
on the trunk. They are unaltered by pressure, and 
have no tendency to coalesce, unless exposed to pres- 
sure, when they seem to run into one another, causing 
vibices or ecchymoses. In their first or circular form 
they are termed petechia. 



PURPURA. 80 

Purpura is usually ushered in with slight fever, and 
with the other usual concomitants of this, viz., thirst, 
headache, and quick yet compressible pulse. In other 
instances the premonitory symptoms may pass unnoted. 
Not merely does the skin suffer as described, but blood 
may also be effused into the several mucous, and occa- 
sionally also into the serous, membranes of the body. 
In these effusions lies the chief danger of purpura, and 
the disease has thus two great divisions: 

Purpura Simplex and Purpura Hcemorrhagica. — 
In purpura simplex the disease runs a simple course, 
with little constitutional disturbance. A few spots are 
probably found dispersed over the body on awaken- 
ing in the morning ; but not aggregated. Two or 
three successive crops may thus form ; and the disease 
usually subsides in from seven or eight days to a 
fortnight. 

Purpura hcemorrhagica is an aggravated form of 
the simple disorder, and in addition is specially char- 
acterized by an effusion of blood into those passages 
of the body lined with mucous membrane. Conse- 
quently, effusions are observed during life on the 
gums, tongue, and inside of the cheek; and, if the 
case ends fatally, they can be seen all over the 
digestive tract. 

Necessarily, the constitutional symptoms are more 
intense, the fever higher, the general oppression more 
apparent than in the other form ; and, in from twenty- 
four to forty-eight hours, spots are rapidly developed 
on the skin. These spots are of a bright-red color 
at first, but deepen into a purple-red. The skin 



84 GENERAL DISEASES. 

becomes tender and blotched, and scratching occasions 
bleeding. 

The same exudation may take place into the mu- 
cous membranes from the first, but it usually follows 
after a few days. From the gums oozing of blood 
may occur, which it is sometimes difficult or impossi- 
ble to check, while from the same cause there may be 
epistaxis, or haemorrhage from lungs, stomach, or 
bowels. Thus there may be great and fatal loss of 
blood, or simply weakness, anaemia, and pallor. 

Diagnosis, — Purpura and scurvy may be confounded 
with one another. They agree in this, that they are 
due to some impoverished state of the blood which 
leads to effusion. They differ, however, as will be 
observed, in certain points. 

Scurvy appears gradually, purpura suddenly, and 
with some premonitory feverish ness. Scurvy is essen- 
tially characterized by sponginess and lividity of the 
gums, while these conditions are absent in purpura. 
A dusky sallow complexion accompanies scurvy, but 
not purpura. Further, scurvy is due mainly to the 
want of fresh vegetables, and can be cured by the ad- 
ministration of these. 

No single error of diet, no single cause, originates 
purpura, and it can neither be prevented nor cured by 
the antiscorbutic remedies. 

Treatment — Ignorant of the cause, we can only treat 
purpura symptomatically. We have no specific as in 
scurvy ; yet, knowing that poverty, bad diet, fatigue, 
and defective ventilation, are great predisposing causes, 



CHLOROSIS. 85 

it is obvious that a good nourishing diet, rest, and a 
well-ventilated room, are essential. 

Ten or twelve drops of dilute sulphuric acid, com- 
bined with one grain of quinine, may be given every 
two hours, or (F. 75). 

When internal haemorrhage occurs, the oil of turpen- 
tine, combined with creasote to prevent nausea, is 
necessary. 

In cases of extreme anaemia there is danger of fatal 
swooning; hence the patient must preserve a hori- 
zontal attitude until all the prominent symptoms of 
anaemia disappear. 

Chlorosis (x* m P°s> 9 reen ), Ajlemia. 

Ansemia, a diminution in the color and specific 
gravity, especially of the red corpuscles of the blood, 
may be associated with many diseases, such as tuber- 
cular, syphilitic, or malignant affections of any organ, 
or general debility, and as such deserves no special 
mention. 

One form of anaemia, chlorosis, seems peculiar to 
young women from the age of puberty to twenty-five, 
and is usually associated with menstrual or uterine 
derangements. 

Symptoms. — The disease is revealed by certain symp- 
toms, the most prominent of which are palpitation and 
a loss of color, causing at first a pale sallow appear- 
ance of the surface, which may deepen into a greenish 
tinge, — hence the name. AVith the palpitation there 
are often combined various abnormal murmurs in the 



8b GENERAL DISEASES. 

heart and bloodvessels. A soft murmur following the 
systole is frequently heard over the base of the heart, 
and along the course of the ascending arch. The 
pressure of the stethoscope on the veins of the neck, 
especially of the right side, evokes a peculiar hissing 
or droning sound (the " bruit de diable"). The res- 
pirations are frequent, becoming markedly increased 
by mental disturbance or bodily exertion; and the 
patient usually complains of shortness of breath and 
inability to do anything, with loss of appetite, and 
pain and flatulence after taking food. Menstruation 
is generally deranged, being sometimes scanty or irreg- 
ular; frequently there is amenorrhoea; neuralgic pains 
in the face and head, or intercostal muscles, are often 
concomitants of the affection. 

The disease tends to recovery in the space of a 
month or two, unless it leads to the development of 
phthisis or gastric ulcer. Relapses are, however, 
common. 

Pathology, — Trousseau regards chlorosis as a nerv- 
ous disease; others consider it due primarily to disor- 
ders of the reproductive or digestive system. Possibly 
it even originates from a combination of various de- 
rangements. It is questioned whether there is a nu- 
merical deterioration in the blood-corpuscles, though 
their quality and color are changed ; the specific gravity 
is reduced, and the color greenish. Virchow noticed 
that in these cases the aorta was found abnormally 
narrow, with thin elastic walls; that there was fre- 
quently fatty degeneration of the muscular structure 



ERYSIPELAS. 87 

of the heart, and many other abnormalities in the cir- 
culatory system. 

Treatment. — Iron is a specific for chlorosis, and 
should be administered in the form of the perchlorides 
with a mineral acid and a vegetable tonic, associated 
with aloes and myrrh pills to correct constipation 
(F. 77, 78). 

Good food, a change of air, and moderate exercise, 
are also essential. 

Erysipelas. 

The term erysipelas is derived from the Greek 
words, ipow I draw, and nekaq near. It is so named 
from its tendency to spread. 

It is an exanthematous inflammation, characterized 
by a redness, more or less acute, on the skin, attended 
with hardness and swelling, and terminating gener- 
ally by resolution or desquamation, though it is some- 
times followed by suppuration, more rarely by gan- 
grene. 

It may be traumatic, following on a wound, or 
idiopathic, dependent on some disordered state of the 
constitution, and not due to any injury. In its latter 
phase it is a medical disease ; and, although it may be 
seen on any part of the body, it usually selects the 
head or face. 

Like other exanthematous affections, it has a period 
of incubation ; unlike them, however, the duration of 
this is not certain, but varies from a few hours to four- 



bb GENERAL DISEASES. 

teen days. Five to seven days may be taken as an 
average. 

It often sets in with chilliness and uneasiness rather 
than with distinct rigors ; and is attended with loss of 
appetite, thirstj and fever, in nineteen cases out of 
twenty. 

This general feverish condition may last a few hours 
or a few days, and then its local phenomena are mani- 
fested in a redness of the skin, more or less circum- 
scribed, accompanied by acute pain, which pressure 
augments. The temperature of the skin is increased 
at the particular spot sometimes as much as three or 
four degrees. 

The redness does not remain localized. It spreads 
from point to point. If it originates in the face, the 
scalp is invaded, and when such is the case the indi- 
vidual features are not recognizable. 

The distended eyelids obscure the eyes, the lips are 
swollen, the mouth is open, speaking is sometimes 
difficult or impossible, the nose acquires an enormous 
size, and the nostrils may be dry or obstructed by 
blood or mucus. 

Usually after a fever of three or four days' dura- 
tion, and in which a temperature of 105° may be 
reached, the redness fades, and the blisters or small 
vesicles which had been formed in the course of the 
disease presents a varying appearance ; in some parts 
being dried into a crust, while in others their contents 
are not yet absorbed, but are undergoing absorption. 

In other cases the vesicles become dark in color, 



ERYSIPELAS. 89 

and the skin beneath is converted into a grayish dis- 
colored slough. 

Suppuration and gangrene ensue, accompanied by 
a low typhoid state of the system, with increased tem- 
perature, extreme prostration, and a fatal issue. 

It may also prove fatal by the extension of the in- 
flammation to the brain or its membranes, by the 
blood-poisoning and malignant character of the dis- 
ease, or by the glottis becoming so swollen as to in- 
duce suffocation. 

Erysipelas is sometimes complicated with bronchitis, 
acute nephritis, and pneumonia. Most English au- 
thorities believe that the disease can be propagated by 
actual contact, or disseminated by means of fomites. 
Atmospheric conditions favor its occurrence, in what 
way we do not know. It has also been observed that 
where puerperal fever prevails there is a predisposi- 
tion to erysipelas in the hospital wards. 

It may be seen in infants, but after infancy it is rare 
until adult life. Acute attacks are most common 
from twenty to forty. Asthenic, or less acute attacks^ 
from forty to old age. The sexes are affected in 
equal proportion. 

Diagnosis. — Erysipelas may be mistaken for scarlet 
fever, measles, or small-pox. The redness of scarlet 
fever is not, however, localized, and it is accompanied 
or preceded by throat complications. In measles 
there are nasal and catarrhal symptoms. A develop- 
ing small-pox pustule may simulate it, but a small- 
pox pustule is not solitary ; others may be seen in dif- 
ferent parts of the body, and there are premonitory 



90 GENERAL DISEASES. 

symptoms in small-pox^ such as vomiting and pain in 
the back. 

Erythema and erysipelas have one feature in com- 
mon, viz., redness ; but they differ in this, that in ery- 
thema there is no fever, premonitory or coexistent; 
there is no inflammation of the deeper-seated parts of 
the skin, there is no vesication, there is no tendency 
to implicate the lymphatic glands, and it does not pe- 
culiarly affect the face or head. 

Treatment. — The patient, if possible, should be 
placed in a cool, well-ventilated apartment, and should 
be freed from all sources of irritation, either by officious 
nursing or fussy friends. 

The medicinal treatment may be fitly commenced 
by a calomel and jalap purgative. Then give tincture 
of steel, in 30 or 40 minim doses, every three hours, 
until the fever is lowered. When convalescence is 
certain, diminish the doses to 20 minims thrice daily 
for two days, after that give bark. 

If the cerebral symptoms are grave, cut away the 
hair ; and if the throat is implicated, let steam be in- 
haled, and the throat touched with tannin and glycerin 
(F. 49). 

The principle of all local applications consists in 
protecting the part affected. The old plan was to dust 
with flour and cover with flannel, or oxide of zinc and 
starch, as being less clogging to the skin, and more 
soothing. After applications such as these, it is un- 
necessary to be too curious in removing the coverings 
to see how things are getting on. 

As a more perfect covering, a mixture of castor oil 



DISEASES OF RESPIRATORY ORGANS. 91 

and collodion has been recommended, or painting the 
whole surface lightly with the nitrate of silver in solu- 
tion, or with the solid stick. 

Dr. Wood is in favor of tincture of iodine as a 
local application. 



DISEASES OF RESPIRATORY ORGANS. 

Accurately and intelligently to understand these, 
it is necessary to be familar with the meaning and 
importance of certain terms which are met with in 
the description of diseases of the chest. The air in 
breathing passes into the trachea, the wall of which 
is rough and irregular in three-fourths of its circum- 
ference, with strongly marked cartilaginous rings, and 
the current of air entering is great and quick. 

Below the bifurcation of the trachea the bronchi di- 
vide into smaller and smaller tubes; the cartilaginous 
rings become less and less distinct, until, in the ter- 
minal ramifications of the bronchi, they cease to exist 
and the tubes are smooth on their internal surface. 

If the stethoscope is placed over the trachea, two 
rough harsh sounds will be heard, the one accompany- 
ing inspiration, the other expiration, with a distinct 
interval between them. This is what is termed 
" tracheal or cavernous respiration." 

Xext, placing the stethoscope on the upper bone of 



92 DISEASES OF RESPIRATORY ORGANS. 

the sternum, opposite the point at which the trachea 
divides into the bronchi, there is heard a modification 
of the tracheal breathing, the character of the sound 
being hollow, blowing, and soft, and with the inspira- 
tion rather longer than the expiration. This is " bron- 
chial respiration " or " tubular breathing." 

Again, placing the stethoscope over other parts of 
the chest, it will be found that the blowing character 
is gone, that the inspiration is soft and gentle, that 
the expiration immediately follows it, and is less pro- 
longed. The combination of the two constitutes the 
healthy vesicular murmur. 

If the person is told to speak when the stethoscope 
is at the different situations mentioned it will be found 
that the character of the voice also varies. Thus over 
the trachea it seems as if he were speaking right into 
it, so loud and full is the sound ; even a whisper can 
be heard. This is " pectoriloquy." 

Over the sternum it is still distinct and clear, but 
not so loud. This is " bronchophony." 

While over other parts of the chest a buzzing 
scarcely audible sound is heard. 

These sounds, as will be seen, are significant of 
various diseases when heard in parts of the chest, 
where in health they are not detected. 

The mucous membrane lining the respiratory tract 
is in health moist, but not too much so, else this also 
would give rise to disease, and as illustrating terms 
used, and various conditions, let us suppose a common 
cold is caught. The effect of this on the mucous mem- 
brane of the respiratory tract, if it extends to it, is, 



DISEASES OF RESPIRATORY ORGANS. 93 

first, to make it dry; secondly, swollen and inflamed. 
The consequence is an alteration in the character of 
the sounds where the vesicular murmur is heard. If 
the larger air-tubes are alone involved a deep-toned 
note will be produced like that of a person snoring in 
sleep, or humming like that of a spinning top ; hence 
it is often described under the terms cooing, snoring, 
buzzing, or technically, " sonorous rhonchi." If the 
dryness extends to the smaller air-tubes the sounds 
are shriller in character — piping, whistling, hissing, 
or technically, " sibilant rhonchi." These sounds may 
occur separately or together, and, if together, there is 
frequently a combination of the characters of both 
heard on auscultation, giving rise to a strange medley 
of cooing, whistling, piping, and snoring. 

The mucous membrane in a cold, although still in- 
flamed, does not remain dry, but becomes moist, and 
hence the dry sounds are replaced by moist ones. The 
air passes through liquids, and, in doing so, gives rise 
to bubbles, and to these liquid sounds the term rales 
is applied. If these are fine, and confined to the 
smaller air-tubes, the term " small crepitation " is used ; 
if on a larger and coarser scale, involving the larger 
air-tubes, they give rise to large crepitation. These 
two liquid sounds may and often do merge insensibly 
into one another, so that they are often heard on the 
same chest during the same complaint. 

It will thus be observed, as the following diagram 
will show, that we have " sonorous rhonchi" and 
"large crepitation " as representing the dry and the 
moist sounds of the larger air-passages; " sibilant 



94 



DISEASES OF RESPIRATORY ORGANS. 



rhonchi" and "small crepitation" in a similar manner, 
being applied to the smaller air-passages. 

Leaving the mucous membrane, as seen in its inflani- 



Fig. 4. 



Large 
crepitation. 



Small 
crepitation. 



Vesicular 
crepitation. 




Sonorous 
rhonchi. 



Sibilant 
rhonchi. 



mation from a common cold, we may say further that 
moist sounds are produced by bubbles of air traversing 
or bursting in a somewhat viscous fluid. Hence they 
may be formed, not merely in the bronchi, but in the 
terminal air-vesicles, or on a larger scale, in cavities 
or ulcers of various sizes. They may thus be fine, 
scarcely audible, or coarse, resembling gurgling and 
splashing, and between these two extremes there are 



CATARRH. 95 

various gradations, hence such terms as "suberepi- 
tant," " mueo-crepitant," etc. 

The chest in health on being percussed gives every- 
where a clear reply, the note on both sides being simi- 
lar in similar situations, unless where on the left side 
the heart intervenes. In the course of some diseases 
it will be found that one side is more expanded or re- 
tracted than the other, and it is necessary to estimate 
the exact difference between them. For this purpose 
mark with ink the central spots over the spinal ver- 
tebrae and the sternum, and stretch a graduated tape 
between them on both sides, telling the patient to hold 
his breath during the experiment. In cases where 
there is any difference, note whether it increases or 
diminishes at regular periodical visits. If your hand 
is placed over the chest when the patient speaks, a 
distinct vibration is communicated to it. This is 
termed " vocal fremitus," which sensation may be 
altered by disease. 

Catarrh. 

We have commenced, and, to a certain extent, illus- 
trated in the preliminary remarks what effect a cold 
has upon the chest when it affects the mucous mem- 
brane of the respiratory tract. It may, however, stop 
at the head, affecting only the nose (coryza) or the 
frontal sinuses (gravedo), giving rise at first to dry- 
followed afterwards by what is termed running 
at the eyes or nose, and a profuse muco-purulent dis- 
charge. The general symptoms attending, vary from 



96 DISEASES OP RESPIRATORY ORGANS. 

weariness and stuffiness of the head to actual headache 
and some distinct feverishness, with inability to attend 
to ordinary duties. 

The question in treatment is to endeavor to keep it 
at its place of origin. How are you to stop a cold ? 
Catch it at its commencement, and feed it by an opiate. 
Twenty drops of tincture of opium, or ten drops of 
liq. morph. and eight of vin. antimon. given twice at 
an interval of three hours will usually accomplish 
this. A simple and effective method has also been 
suggested — viz., to take no liquid of any kind for 
twenty-four or forty-eight hours. In this way the 
materials for flux are minimized, and it dies of inani- 
tion. A Turkish bath can also be recommended. 



Laryngitis, etc. 

The extension of a common cold to the larynx, 
leading to congestion and slight inflammation of the 
mucous membrane, is by no means uncommon. It is 
evidenced by hoarseness, soreness in drawing a breath, 
and a dry tickling cough. " Acute laryngitis" is a 
much more severe, and, fortunately, rare affection; 
peculiar, generally speaking, to adults, and due usually 
to exposure to cold, or inhaling vapors or dust. 
(Edema of the glottis may be produced immediately 
by the fumes of nitric and sulphuric acids, and by the 
accidental swallowing of boiling water. Sore throat 
is complained of, and is referred to the pomum Adami. 
The inspiration is protracted, wheezing, and laborious; 
the expiration comparatively easy, the voice hoarse or 



LARYNGITIS, ETC. 97 

altogether lost, the face flushed, with livid lips, the 
fever high, and a peculiar imperfect cough is present. 
These symptoms, following rapidly on one another, 
are accompanied by intense restlessness and a feeling 
of suffocation — which actually does take place unless 
relief is afforded — with drowsiness, delirium, and coma. 
The patient dies strangled, and the cause of this is, as 
the symptoms indicate, due to the chink of the rima 
glottidis becoming closed from the swelling of the 
mucous membrane lining it, or from inflammatory 
effusion into the subjacent areolar tissue. The course 
of the disease is rapid, sometimes carrying off the 
patient in twelve hours, or at all events before the 
fifth day. At other times recovery ensues; or the 
affection may pass into chronic inflammation. 

Chronic laryngitis is characterized by tickling, dry- 
ness, cough, and soreness of the throat, and congestion 
of the pharynx or larynx. It is not usually danger- 
ous to life, and is often the result of over-exertion of 
the voice in clergymen, public speakers, or singers. 
" Ulceration of the larynx" may precede, or more fre- 
quently accompany, advanced cases of phthisis. It is 
also not uncommon as the result of secondary syphilis. 
" Tumors," or " polypi," may also form on the larynx, 
and give rise to symptoms like those of chronic laryn- 
gitis. They are recognized by the laryngoscope, and 
can sometimes be removed. 

Treatment in acute laryngitis must be prompt to 
be effectual, and consists in tracheotomy being per- 
formed, thus allowing rest to the inflamed part, and 
relief to the engorged lungs (Porter). The after-treat- 



98 DISEASES OP RESPIRATORY ORGANS. 

ment must be conducted on the principle of support- 
ing the patient's strength by rnilk ? beef tea, and wine 
or brandy, if there be, as there usually is, much de- 
pression. Short of tracheotomy, general bloodletting 
sometimes does good. Scarification of the swollen 
parts by a curved bistoury protected to within a quarter 
of an inch of the point, has been followed by relief of 
the severe paroxysms. For chronic laryngitis, chlor- 
ide of zinc has been specially recommended as a local 
application, in the proportion of thirty grains to the 
ounce of water every day for a week, and afterwards 
on alternate days until amendment occurs. Tannin, 
with glycerin, is useful in phthisical, and nitrate of 
silver in syphilitic ulceration. If the secretion is ex- 
cessive, turpentine or creasote may be inhaled ; or if 
the irritation is great, inhalation of hops or chloroform 
with the steam of boiling water may give relief. Rest, 
a dry climate, the careful wearing of flannel, and some- 
times of a respirator, form valuable adjuncts, and in 
some cases are essential to the general treatment (F. 
49, 52, 53). 

Diphtheria. 

Although this disease seems to have been well 
known to the ancient physicians, yet its existence in 
England under the term diphtheria (a skin or mem- 
brane) dates back only to 1856, when it spread from 
France to this country. The first accurate investiga- 
tions into the nature of diphtheria were made by M. 
Bretonneau in 1821. He considered that it was wholly 
a local disease, spreading by contagion through the 



DIPHTHERIA. 99 

inoculation of the soft mucous membrane with the 
diphtheritic secretion. He was subsequently obliged 
to concede that blood-poisoning is one of its essential 
characteristics. Much controversy has been excited 
as to the causation of diphtheria, which hinges round 
the inquiry, Is it a local or constitutional disease in 
its origin ? Does the constitutional disease cause the 
local exudation ; or does the local exudation originate 
the constitutional disease? 

In support of the first hypothesis the epidemic char- 
acter of the disease has been insisted on ; the grave 
and serious disturbance of the system, with only a 
few minute exudations observed on the fauces, and 
the impossibility of destroying the diphtheritic process 
by any amount of cauterization. 

In support of the second hypothesis it is urged that 
diphtheria fixes itself at the point of inoculation, as 
shown by experiments on animals, and radiates from 
thence all over the body. Thus it is seen earliest and 
most constantly on the parts swept over in the acts of 
respiration or eating and drinking, when it attacks the 
human subject. Further, the diphtheritic process is 
always associated with vegetable organisms (micro- 
cocci), and their development poisons the blood. 

"Without entering further into the controversy, it 
may be stated that the results of diphtheritic inflam- 
mation are peculiar. Redness and swelling of the 
parts affected are succeeded by patches of lymph, 
which start from one or several points. This lymph- 
ous exudation is of a grayish ashy-white color, and its 
consistence is like that of wetted parchment or damp 



100 DISEASES OF RESPIRATORY ORGANS. 

wash-leather. It can be stripped off, leaving a raw 
and bleeding surface, which is again speedily covered 
over with characteristic exudation. Not merely is 
there exudation, but there is often also on the site of 
the exudation marked ulceration, sloughing, or ab- 
scesses. In fact, true diphtheritic inflammation may 
be considered to be one of substance involving the 
mucous membrane, and tending to slough. Further, 
it may be stated that diphtheria seems to spread by 
direct contagion, and that bad hygienic conditions, 
especially defective drainage, appear, if not actually 
to originate it, at least to foster its occurrence. 

Symptoms. — The general features of diphtheria are 
prostration, restlessness, and muscular debility, with 
headache and nausea, and a sense of stiffness and sore- 
ness about the neck and the angles of the jaw. Fur- 
ther, there is often marked blanching. The local 
effects of the disease are manifested by the exudation 
first on the tonsils, and from thence spreading in dif- 
ferent directions. Thus it may creep backwards and 
upwards into the posterior nares ; or, more frequently, 
it passes over the epiglottis into the larynx and trachea. 
Attacking parts so intimately connected with life, the 
local gravity of the disease is obvious, and death may 
be caused by suffocation ; or, on the other hand, the 
grave constitutional disturbance may result in death 
by asthenia, either directly or through paralysis of 
certain nerves. 

The tongue is generally not much furred, the breath 
is fetid, saliva dribbles from the mouth, and there is 
great difficulty in and disinclination for swallowing. 



% DIPHTHERIA. 101 

The submaxillary glands are enlarged, and, owing to 
the extension of the disease to the larynx, difficulty 
of breathing is a common late symptom. The fever 
is not great. The urine is found albuminous in fifty 
per cent, of the cases. 

In non-fatal cases the specific disease is supposed 
to terminate on the seventh day, although the con- 
valescence after this is slow and attended with great 
depression. After the complete healing of the local 
lesions, in the course of the second or third week of 
the disease various sequels may ensue, viz., paralysis 
of the soft palate and pharynx, paralysis of the mus- 
cles of the larynx, occasioning in the one case difficult 
deglutition, in the other impaired voice. Sometimes 
there are great disturbance of vision and progressive 
paralysis of the extremities. 

Treatment. — If, as later investigations indicate, diph- 
theria is at first a localized disease with after constitu- 
tional symptoms, it is obvious that treatment must be 
local and general. Tearing off the membranous exu- 
dation is absolutely negative, and even thorough cau- 
terization has not been attended with much success. 
It is said that nature unaided in diphtheria tends to 
heal by suppuration, and that in this way the false 
membrane is thrown off. Hence it has been suggested 
by Oertel to imitate nature and to establish a rapid 
and abundant production of pus by means of hot in- 
halations in quarter-hour sittings every half hour; 
with nourishment supplied during the intervals, and 
allowing a longer time to elapse as the membranes 
are thrown off. The mouth should also be rinsed and 



102 DISEASES OF RESPIRATORY ORGANS. 

throat gargled with a solution of carbolic acid, per- 
manganate of potash, etc. 

In the general treatment an even temperature of 
65° to 68° Fahr. is essential, with plenty of milk, ice, 
and cooling drinks, with alcoholic stimulants if the 
powers are failing. The best internal remedy appears 
to be tincture of the perchloride of iron, given in 
large doses (30 minims every two hours in water 
or glycerin). Iodide of potassium and chlorate of 
potass have also been advocated. If the disease at- 
tacks the larynx and is advancing in severity, trach- 
eotomy should be performed as soon as possible 
(F. 5, 7). 

For the secondary paralysis of diphtheria, tonics, 
change of air, and careful electric stimulation by the 
constant current are recommended. 

Croup. 

Two forms of croup are recognized. One form, 
having no inflammatory cause, no structural change, 
is considered to be of a nervous origin. It is termed 
u false or spasmodic croup," or " laryngismus stridu- 
lus." In the other form, true croup, there is local 
and catarrhal inflammation of the larynx or trachea, 
and this inflammation is accompanied by an exudation 
of false membrane on the parts attacked. 

Inflammatory or true croup is a disease of early life ; 
for although it may occur at any time between wean- 
ing and puberty, its most common epoch is in the 
second year of childhood. 



CROUP. 103 

It seems to attack boys more frequently than girls. 

The chief seat of croup is said to be the trachea, 
but it may extend from this to the smallest bronchi, 
and hence bronchitis or pneumonia may complicate 
croup. The vessels of the mucous membrane of the 
trachea exude a material which stiffens and forms a 
layer of false membrane. In some cases it can be 
wiped off easily, in others it requires force to remove 
it ; hence it is said to be thick or thin, diffluent or 
consistent. Tfris stiffened croupal formation obstructs 
the breathing directly, gives rise to a spasmodic con- 
traction of the muscles of the larynx, and diminishes 
the calibre of the air-tubes. Serious results from this 
cause ensue, and in addition shreds of the false mem- 
brane partially detached may produce fatal spasm. 
The inflammation is essentially a simple non-specific or 
fibrinous one, confined to the surface, and hence dis- 
tinct from the diphtheritic. 

Symptoms. — A premonitory feverish catarrh, such 
as occurs in other chest affections, may attract atten- 
tion. If this catarrh be accompanied with hoarseness 
in young children, croup is to be apprehended. Pre- 
ceded or not by this feverish cold, when croup is 
well established it is characterized by marked symp- 
toms. The cough is brassy and ringing; the inspira- 
tion is loud and crowing ; the fauces are observed to 
be red and swollen. 

As the disease advances the fever increases, and 
from the obstruction to the passage of air and the 
proper arterialization of the blood, the skin gets dusky, 
the feet cold, and the pulse feeble. 

The character of the cough ceases to be ringing 



104 DISEASES OF RESPIRATORY ORGANS. 

and becomes husky. There is great irritability and 
restlessness, the child frequently attempting to thrust 
its fingers down its throat to take away the obstruc- 
tion. If the case proceeds to a fatal termination, the 
breathing becomes more and more labored, the face 
pale and livid, cold clammy sweat forms, and drowsi- 
ness deepens into coma and death. Favorable symp- 
toms are the cessation of the crowing inspiration, the 
cough becoming moister and accompanied by expecto- 
ration of false membrane. 

The duration of croup is usually five days. 

Diphtheria and croup are closely allied, yet they are 
supposed to differ in this, that diphtheria is epidemic 
and contagious, is not so sudden in its attack, is not 
limited so much to the trachea, but beginning at the 
pharynx may so spread as to involve the whole re- 
spiratory tract, and membrane may be found in other 
regions ; — that, in fact, according to one theory, it is 
a specific constitutional disease, with throat complica- 
tions ; while croup is a local disease giving rise to 
constitutional symptoms. 

Further, diphtheria is accompanied often by albumi- 
nuria and swelling of the submaxillary glands and fol- 
lowed by paralytic sequelae. It is also much more 
asthenic than croup. The membrane in croup does 
not appear so often as in diphtheria. 

Treatment.— Formerly leeches were always applied 
in cases of croup ; now the most consistent line of 
practice seems to use them only where children are 
vigorous and plethoric. Leeches cannot stop the ex- 
udation, but they seem to prevent the swelling and 
infiltration which might prove fatal. They are ap- 



CROUP. 105 

plied to the manubrium sterni, not to the larynx, as 
the bleeding is difficult to restrain. They ought never 
to be applied to puny and badly fed children. Emetics 
are useful, and of these the sulphate of copper is to be 
preferred to zinc, as tending less to weaken the sys- 
tem. Ten to fifteen grains should be dissolved in two 
ounces of water, and a large teaspoonful of this given 
every five minutes until vomiting is produced. Ipe- 
cacuanha may also be used — a teaspoonful of the wine 
being given at frequent intervals until the child vom- 
its (F. 42). 

If the vomiting relieves the dyspnoea and expels 
the false membrane, it has done good and ought to be 
repeated. If it fails in these objects its repetition is 
contraindicated. A solution of nitrate of silver should 
be applied at intervals of several hours to the entrance 
into the larynx. The bowels should also be acted on 
either by an enema or calomel. If, with the addition 
of a warm bath, hot pack, or hot sponging, these means 
fail, after a trial of twelve hours, tracheotomy should 
at once be resorted to. 

Niemyer says, " If it does not cure, it makes death 
less terrible." 

The diet should consist of milk and nourishing 
soups. Inhalations of simple steam or medicated va- 
por, containing hops, chloroform, or benzoin, are often 
pleasantly palliative (F. 52). 

AVhen the disease has terminated favorably, the 
cough should be encouraged by a mixture of carbonate 
of ammonia and squills in an infusion of senega 
(F. 44). 



106 diseases of respiratory organs. 

False Croup. 

Non-inflammatory croup, to which also the names 
of " laryngismus stridulus," "spasm of the glottis," 
" spasmodic croup," and " spurious croup," have been 
applied, is met chiefly in scrofulous rickety children of 
one or two years of age. It may originate from the 
brain, as in hydrocephalus, or from direct irritation of 
the vagus or recurrent nerves, or from tumors or en- 
larged thymus gland, or from reflex causes, or from 
dentition, worms, improper feeding, mental emotion, 
fright, or anger. 

Symptoms. — The attack is sudden, usually occurring 
at night and during sleep, and is characterized by one 
prominent symptom, dyspnoea. No air enters the 
glottis for the moment, and respiration seems to cease. 
The child struggles for breath as if it were about to 
die from suffocation. There may be also convulsions 
and a contracted state of the flexor muscles of the 
thumb, fingers, and toes (carpo-pedal spasms). 

The paroxysm ceases suddenly, but may be suc- 
ceeded by others, and death sometimes takes place 
through suspended respiration, or by the stagnation 
of the blood in the lungs, heart, or brain. The train 
may be laid for serious after-results, and although 
termed false croup the disease is not free from peril. 

It is chiefly distinguished from true croup by its 
sudden accession and sudden departure, by the free- 
dom of breathing between the paroxysms, and by the 
absence of fever, hoarseness, and any attending cough. 

Treatment — During the paroxysm place the child 



HOOPING-COUGH. 107 

in a warm bath, apply a hot sponge to the throat, and, 
after being taken from the bath, or before it, sprinkle 
the face and chest with cold water. 

As prophylactic remedies against its" recurrence, 
regulate the bowels, lance the gums if hot and tender, 
and recommend fresh air and nutritious diet. 

Depending as it frequently does, on a rickety state 
of the system, 5 to 10 grains of the phosphate of lime 
may be given thrice daily in chalk mixture. 

Hooping-cough 

Is an infectious disease, occurring usually in child- 
hood, preceded by a catarrh of from three to fourteen 
days' duration. Succeeding this there is a peculiar 
cough of a paroxysmal character, which is pathogno- 
monic of the disease. Hooping-cough usually ter- 
minates in six weeks ; at times it may be prolonged 
from two to three months. It is not attended w r ith 
much danger per se, but it may, and often does, origi- 
nate various chest diseases, notably emphysema. 

When hooping-cough has fairly determined itself, 
its features are very characteristic. The child has 
usually some premonitions of an attack, and runs to 
its mother or nurse for protection. Then commences 
a paroxysm of expiratory efforts and cough, with no 
intervening inspiration. The child becomes black in 
the face, and it would appear as if suffocation were 
imminent, when a long-drawn inspiration takes place, 
attended with a peculiar crowing sound. This sound 
is doubtless due to the air entering the contracted, or 



108 DISEASES OF RESPIRATORY ORGANS. 

even partially closed, rima giottidis. When expan- 
sion of the glottis has been completed, and the air is 
permitted to enter freely, the fit for the time is over. 
Or a succession of forcible expirations and cough alter- 
nate with crowing inspirations, until a quantity of 
mucus is brought up, or actual vomiting ensues. 

The paroxysms occurring in the twenty-four hours 
vary as regards intensity. As a rule, they are worse 
at night. During the early stages of the disease the 
mucus expectorated is thick and sticky, but after- 
wards, with the decreasing intensity of the paroxysm, 
it becomes thinner, more abundant, and more easily 
brought up. 

Listening during the intermission of the paroxysm 
you hear simply catarrhal sounds, or perhaps nothing 
abnormal. During the expiratory paroxysm wheezing 
may be detected, but during the long-drawn inspira- 
tion no sound can be heard in the lungs at all. This 
may be partly explained by the slowness with which 
the air enters by the contracted glottis, and partly, as 
Laennec says, by " the spasmodic contraction of the 
muscular or contractile fibres of the bronchi not allow- 
ing the air to enter." 

Etiology, — The absence of fever in hooping-cough 
negatives the idea that the disease is due to inflamma- 
tion ; and it has been urged, from its spasmodic char- 
acter, that it is probably dependent on irritation of the 
pneumogastric nerve by some peculiar poison. Some 
consider that this poison affects the cervical glands, 
which lie in the course of the nerve itself or the recur- 



* HOOPING-COUGH. 109 

rent, causing enlargement of these, as in a similar 
manner the parotid is enlarged in mumps. 

Fatal cases usually exhibit pulmonary collapse — the 
lobular pneumonia of former writers ; and with this 
there is also evidence of bronchial inflammation. 

Treatment, — The disease tends to run its course like 
all specific diseases, and the rule of practice appears to 
be best met by warding off complications and treating 
symptoms. Avoid all gastric irritation by keeping 
the patient on a regulated diet, with plenty of milk 
and little meat, and attend carefully to the bowels. 

Dr. Fuller recommends — 

R. Zinc, sulphat., .... gr. viij. 
Ext. belladon., .... gr. vij. 
Aq., §iv. M. 

A tablespoonful four times a day. For a child above 
three years old with hooping-cough, every other day 
the strength of the mixture may be augmented in the 
proportion of one dose. The belladonna is thus grad- 
ually increased to doses of five grains without mis- 
chief. Dr. Fuller states that by these means the hoop 
rarely lasts more than twenty-one, and may terminate 
in ten days. 

Xitric acid has been employed successfully by Dr. 
Gibb. Bromide of potass and hydrate of chloral and 
carbonate of iron have also been highly spoken of; so 
also have inhalations of carbolic acid (F. 15, 53 a). 

Locally, Roche's embrocation has considerable pop- 
ularity among the poorer classes. 

If bronchitis sets in, poultices should be applied to 
10 



110 DISEASES OF RESPIRATORY ORGANS. 

the chest, probably after leeching, with antimonial 

and ipecac, wine internally, followed, if requisite, by 

stimulants. 

■ Head Symptoms. — Squinting, convulsions, or stupor 

must be met by small and repeated doses of hyd. cum 

cret., warm baths, etc. 

Niemeyer says, " Hooping-cough can be cured on 
the principle that c he who spareth the rod spoileth the 
child/ and that the cough of hooping-cough is not an 
exception to the physiological law, c that violent reflex 
symptoms are controllable by the will/ " Hence he 
advises coercion, the promise of no bonbons or toys 
if coughing is persisted in, and states that the effects 
of this mental dietetic are admirable. 

It is a question whether patients should be allowed 
out in the open air. In all but acute stages this may 
be permitted with much benefit, especially in the ward- 
ing off of succeeding tubercular disease. 

Influenza. 

This term is of Italian origin, indicating something 
fluid or transient, and first applied by Pringle in 1752 
to designate a disease epidemic in its nature and at- 
tended with catarrh, especially affecting the respira- 
tory and digestive organs. It can be traced back with 
certainty to the sixteenth century, and since then ninety 
epidemics of more or less severity have been described. 
Its universality in later years has greatly diminished. 
An epidemic has not been noted for some time. 

In 1837 it w T as very prevalent in London; nearly 



INFLUENZA. Ill 

the whole population was attacked, and the mortality 
was great. 

The cause of the disease seems to be sui generis, and 
dependent on some poisonous influence in the atmos- 
phere, the nature of which is unknown. Influenza 
rarely ends fatally, and when it does, reveals no char- 
acteristic post-mortem features, there being simply 
swelling and redness of the respiratory tract, with 
signs of hyperemia also in the oesophagus and stomach. 

Symptoms. — The onset of the disease is sudden, 
hence the term "lightning catarrh." There is first a 
chill and malaise for several hours, followed by fever, 
most marked at night. There is also a dry torment- 
ing convulsive cough, with a fulness of the head, red- 
ness of the conjunctiva, throat, and mouth, and swell- 
ing of the tonsils and difficulty of swallowing. The 
sputa are scanty and muco-serous. There is intense 
prostration from the first, with dragging pains in the 
limbs and utter inability to move about. 

The disease lasts four or five days, and usually ter- 
minates in a critical sweat, with diarrhoea and an in- 
creased secretion of urine. During an epidemic of 
influenza the death-rate of a town is increased, especi- 
ally among the aged and feeble, through its setting up 
acute bronchitis or inflammation of the lungs. 

The great number of persons attacked and the severe 
prostration distinguish influenza from an ordinary 
catarrh, with which alone it can be confounded. 

Treatment. — By rest in bed, quietness, and a stimu- 
lating expectorant, influenza is best treated. Opium, 
inhalations of steam, and counter-irritants, are useful 



112 DISEASES OP RESPIRATORY ORGANS. 

for the cough. Relief will be afforded to the head- 
ache by smearing the face with fat or snuffing up a 
solution of morphia in the proportion of 1 to 50 or 
60 of cherry laurel water. During convalescence give 
quinine and iron. The diet should consist of mucilag- 
inous drinks and nourishing soups, with stimulants 
when the debility is great (F. 43). 

Bronchitis 

Is an essentially inflammatory affection of the bron- 
chial mucous membrane, and may be either acute or 
chronic. 

It is caused by exposure to cold or wet. local irri- 
tation from mechanical operations, e.g., needle-grind- 
ing, or it may be dependent on heart disease, or asso- 
ciated with various constitutional affections, such as 
rheumatism, gout, fever, Bright's disease. It is most 
common in childhood and old age. 

Two varieties of acute bronchitis have been recog- 
nized : 

1. When the larger and medium-sized air-tubes are 
alone affected. 

2. When the inflammation does not stop there, but 
involves all the bronchial ramifications — capillary or 
general bronchitis. 

The last form is rarely seen in adults, but chiefly 
among young children and old people, and is fre- 
quently fatal. 

Certain general symptoms accompany both varie- 
ties. Thus, there is chilliness, fever, running at the 



ACUTE BROXCniTIS. 113 

eyes and nose, and general malaise. The extension of 
the inflammation down the respiratory tract causes 
irritation of the mucous membrane of the larynx 
and trachea, as is evidenced by a sense of tightness 
behind the sternum and a tickling sensation about 
the windpipe. The expectoration is at first dry and 
difficult to bring up, scanty, white, and frothy ; but in 
the course of a few days, or a few hours, it increases in 
quantity, and if the attack be severe or prolonged, it 
becomes muco-purulent. 

In the more severe form the symptoms, correspond- 
ing to the gravity of the case, are more urgent. The 
restlessness is great, the fever high, anxiety is depicted 
on the countenance, and the impaired and impeded 
circulation through the right side of the heart is evi- 
denced by the livid lips; and this lividity sometimes 
extends over the body, and is observed at the finger 
ends. Should the disease terminate favorably, there 
is a gradual remission of the severity of the symp- 
toms. The fever decreases. Respiration becomes 
easier, the cough less troublesome, and the expectora- 
tion freer. But if a fatal termination is likely, the 
symptoms increase in severity. Unable to sit up in 
bed, the patient sinks exhausted on the pillow. The 
breathing is thus more difficult, and the lividity be- 
comes more intense. There is not the power to bring 
up the mucus, which accumulates in the air-passages, 
and thus the patient dies from suffocation, or from 
apnoea, due to the arrest of the circulation through 
the lungs, in consequence of the coagulation of blood 



114 DISEASES OF RESPIRATORY ORGANS. 

in the pulmonary arteries and in the right cavities of 
the heart. 

On auscultation during the first or dry stage of 
bronchitis we detect two coarse rough dry sounds all 
over the chest. The air-tubes are narrowed, but the 
air does not come through mucus ; hence the dryness 
of the sounds, which are termed rhonchi if the larger 
tubes are implicated, sibili if the smaller ones are in- 
volved. Percussion in this stage is clear. 

When the secretion of mucus commences these dry 
sounds are replaced by large bubbling in the larger 
air-tubes, or small bubbling if the disease has reached 
the smaller tubes. This has been termed the moist 
stage of bronchitis, and the sounds then heard have 
been technically called large and small crepitations. 

Percussion may sometimes detect dulness through 
cedema at the base of either lung ; while, if there is 
pulmonary collapse through tenacious mucus plugging 
up a bronchial tube, as not unfrequently happens, the 
percussion-note will lack resonance over that particular 
part. 

Prognosis. — From three-fourths to one-half of those 
attacked with capillary bronchitis die between the 
sixth and tenth days of the disease. In favorable 
cases improvement commences from the fourth to the 
eighth day. Bronchitis affecting the larger air-tubes 
is not dangerous. Relief generally supervenes when 
expectoration becomes abundant. Should this fail to 
return, pulmonary congestion ensues, and ultimately 
death. Circumstances increasing the gravity of the 
prognosis are very early or advanced life, the exist- 



ACUTE BRONCHITIS. 115 

ence of some acute or chronic disease, or other com- 
plications. 

Anatomical Appearances. — The morbid appearances 
directly indicating bronchitis as a distinct affection 
may be summed up in one word — redness, which may, 
however, vary in intensity. With the redness there 
is swelling;, and at first dryness of the mucous mem- 
brane. The dryness is afterwards replaced by a muco- 
purulent secretion. 

Treatment. — Every case of bronchitis must be treated 
individually, as no general rule can be laid down. 
Yet it may be stated that bronchitis, during its early 
catarrhal stage, may be prevented from proceeding 
farther by the administration of a full dose of opium 
or wine in whey. If the fever is too intense for this, 
a hot bath, followed by a weak saline purgative, 
and diaphoretics and expectorant mixture, must be 
trusted to. 

R. Oxymel seillge, ^ss. 

Sp. seth. nit., 

Tinct. camph. co., aa . . . . gj. 

Mist, amygdal., gj. M. 

S. "To be taken every six hours for adults." 

Or antimonial wine, with liq. acet. amnion., for 
children, in doses proportioned to their years, or (F. 
34, 45). 

Bronchitis occurring in people of a gouty habit 
must be met by adding cole hi cum to the above-men- 
tioned formula. The antimonial mixture may be 
omitted when the expectoration becomes freer. Steam 



116 DISEASES OF RESPIRATORY ORGANS. 

or medicated inhalations are very grateful. When 
the depression is extreme and the lividity great, car- 
bonate of ammonia must be trusted to. 

Local applications will consist of sinapisms, turpen- 
tine stupes, jacket poultices of linseed meal, etc. The 
diet should be fluid, milk, beef tea, gruel, arrowroot, 
in ordinary cases, and to these wine or brandy must 
be added in the more severe types of the disease. 

In sthenic cases, occurring in adults, cupping, or the 
application of a few leeches, has been strongly recom- 
mended. General bloodletting has now been practi- 
cally abandoned. 

Sometimes, as the result of various chronic lung 
affections — as bronchitis, emphysema, or interstitial 
pneumonia — a bronchial tube may become so dilated 
as to form a single pouch, like an aneurism of an artery, 
or a series of pouches in the same tube. This condi- 
tion is termed bronchiectasis, and if the cavity is near 
the surface, and contains air as well as liquid, the 
signs will be identical with those of a phthisical cavity. 
The breath is very offensive, and the expectoration 
abundant and fetid. 

Chronic Bronchitis 

Sometimes follows the acute form, or it is the result 
of general bad health, or the sequela of what is termed 
coughs and colds. It is common in advanced life, ap- 
pearing in wintry inclement weather, and disappear- 
ing in summer. It may vary in its severity, at times 
being attended with little or no uneasiness except a 



CHRONIC BRONCHITIS. 117 

slight cough and some expectoration ; in other cases 
the cough is very harassing, especially in the morning, 
the expectoration copious and resembling very much 
the nummular sputa of phthisis, or it may simply be 
frothy and muco-purulent. Fresh exposure to cold 
or atmospheric changes may at any time convert 
chronic into a dangerous form of acute bronchitis. 

Chronic bronchitis is sometimes dependent on cer- 
tain constitutional diseases, as syphilis, gout, rheuma- 
tism. It also specially affects workers at certain occu- 
pations, e. g., knife-grinders, miners, cotton opera- 
tives, etc. Auscultation after free expectoration reveals 
loud harsh sounds all over the chest. These are best 
described as snoring. They vary in their intensity 
according as the air-passages are well cleared from 
mucus, or the reverse. In advanced cases the respi- 
ration is of a hollow blowing character, and attended 
with gurgling. Percussion is unaltered unless there 
is great accumulation of matter to be expectorated, 
when it may be temporarily dull over a particular 
spot. 

Treatment. — Indications for treatment vary accord- 
ing to the different forms of the affection, but, in all 
cases, are based on certain obvious principles. The 
patient should always be w r ell clad, flannel being con- 
stantly worn, and he should be exposed as little as 
possible to the vicissitudes of the weather. During 
winter, if circumstances admit, the patient should 
reside where the climate is mild and dry. In addi- 
tion, an attempt must be made to relieve the cough, 
to promote or restrain free expectoration, and subdue 



118 DISEASES OF RESPIRATORY ORGANS. 

spasm. As stimulating expectorants, vin. ipecac., 
squills, and senega may be mentioned. Jn checking 
the expectoration, when excessive, tincture of benzoin, 
dilute sulphuric acid, and the various preparations of 
opium may be employed. Inhalations of steam alone, 
or charged with hops, or w T ith dilute hydrocyanic acid, 
are serviceable for the cough or spasm. The treat- 
ment for bronchiectasis can only be palliative (F. 44, 
45, 21, 52). 

Emphysema. 

There are three kinds of emphysema usually de- 
scribed by pathologists, viz., interlobular, lobular, and 
senile. These terms explain themselves, hence we 
shall postpone the separate consideration of them until 
w r e come to speak of the pathology, especially as the 
symptoms of the three forms are the same. 

Symptoms. — The patient generally has a livid or 
cyanotic appearance, and, if he be otherwise healthy, 
this points to a deficient aeration of the blood. In 
this disease also we find pigeon-breast in the child, 
and barrel-shaped chest in the adult. The history is 
of great importance, for, if the patient has had chronic 
bronchitis, asthma, tubercle, or violent hooping-cough, 
or difficult establishment of respiration in childhood, 
we may suspect emphysema. 

Dyspnoea, with a distressing feeling of oppression 
behind the sternum, accompanied by cough, with 
opaque yellow expectoration, are pretty constant signs. 

Physical Signs. — Regarding the percussion-note 



EMPHYSEMA. 119 

there is much difference of opinion, some saving it is 
abnormally resonant, others that it is normal or dull 
(Gairdner). The respiratory murmur is deficient, and 
there are sonorous rales, and in rare cases crepitation. 
Vocal resonance is deficient, and the heart-sounds 
feeble or masked. The liver and heart are frequently 
depressed, and the latter may be pushed to one side if 
one lung only is affected. 

Prognosis. — This is most unfavorable, for although 
not so fatal as tubercular disease, emphysema is very 
intractable, disabling, and permanent. 

Pathology. — 1. Interlobular Form. — The air-vesicles 
may be ruptured from without as by a broken rib, or 
from within as by obstruction of the larynx from 
croup or diphtheria, causing great pressure. Thus air 
escapes into the connective tissue outside the vesicles, 
from which it may pass to the root of the lung, neck, 
or the subpleural tissue. 

2. Lobular, or ordinary emphysema, is an inflation 
of the terminal air-cavities, with atrophy and destruc- 
tion of intervening septa from mutual pressure, ending 
in large cavities. This may be local or general, and 
the lung-tissue is bulky, although pale, and collapses 
on section. There are three views as to the cause of 
this— 

a. That there is a primary degeneration of lung- 
tissue, as in senile emphysema, to be noted afterwards. 
It may also occur in hereditary emphysema. 

6. That violent expiratory efforts with closed glottis 
cause increased pressure, which acts on the least sup- 
ported parts of the lung; and it is in these positions 



120 DISEASES OF RESPIRATORY ORGANS. 

that we most frequently find emphysema, viz., at the 
outer margin, apices, and margins of base. 

c. Inspiratory Theory. — When a portion of lung 
contracts, or adhesions exist, rendering inspiration 
impossible, some other part of the lung must be over- 
distended during inspiration, hence emphysema occurs, 
and we often find emphysematous vesicles round cica- 
trices at apex, or round adhesions. 

3. Senile emphysema is simply an atrophy of the 
tissue between the vesicles, and between the infun- 
dibula. 

Pulmonary emphysema, owing to the great obstruc- 
tion to the pulmonary vessels, causes hypertrophy of 
right side of the heart, leading on to tricuspid insuffi- 
ciency and general venous congestion. 

The loss of inspiratory surface causes the breathless- 
ness. 

Treatment- — We can only palliate. Patient should 
be clothed in flannel, and avoid damp and cold. He 
should be very temperate in living, and if possible 
enjoy a warm climate. Medicinally, smoking stra- 
monium cigarettes, or the use of arseniate of soda, or 
potash-nitrates, may give relief. The latter may be 
prepared thus (F. 51). 

If the cough is very troublesome, an expectorant 
with ether may be given. If much difficulty in ex- 
pectorating, an emetic of ipecac, with sinapisms to 
feet and calves of legs, may be tried. If indicated, 
any of the antispasmodics may be of temporary benefit 
(F. 12, 13). 



ASTHMA. 121 



Asthma 



Seems to be essentially a spasmodic disease, the 
patient being healthy in the intervals, although during 
the paroxysm, which seldom proves fatal, suffocation 
seems imminent. 

Symptoms, — The first invasion takes place during 
sleep. The patient wakens to find that he can scarcely 
get breath, hence he puts himself into the position that 
gives him most purchase for breathing. Respiration 
is accompanied by great wheezing, and yet hardly any 
respiratory murmur is heard. Tidal air is much dimin- 
ished. Patient feels that if he could cough and expecto- 
rate he would be relieved, but this he cannot do till the 
end of the paroxysm. The extremities are cold, the 
face livid, and the expression anxious. Pulse small 
and quick, but no fever. Towards the end of the 
paroxysm the expectoration appears, and is found to 
consist of frothy mucus free from blood or pus. 

Such patients are usually thin and round-shouldered, 
and the attacks often appear to take on a periodic char- 
acter. Asthma is most frequent during middle life, 
affecting men more than women, and being often 
hereditary. 

Asthma is termed idiopathic or spasmodic when un- 
complicated, and symptomatic or organic if it accom- 
panies bronchitis, heart disease, etc. 

Causes. — Direct. — As irritating inhalations, or over- 
eating, leading to distension of the stomach and pres- 
sure on the diaphragm. 



122 DISEASES OF RESPIRATORY ORGANS. 

Indirect. — Through nervous system, as by strong 
emotions. 

Prognosis. — In itself most favorable, but by its 
complications, as congestion of lung, emphysema, and 
hypertrophy of heart, it is of much more serious im- 
port. 

Pathology.— Asthma consists essentially of a spas- 
modic contraction of the muscular fibres of the bron- 
chial tubes, by which means the admission of air is 
diminished, and the tubes become blocked up with 
expectoration, which it is partly the function of the 
muscular fibres to expel. 

Treatment. — During the Paroxysm. — First thing is 
to procure fresh air, and remove any tight clothing 
from neck and chest. Medicinally, stramonium, in 
the form of cigarettes or in a pipe, frequently gives 
relief. Tobacco also has been found useful. Inhala- 
tion of chloroform should be tried, care being taken 
to stop it if the lips become blue. Burning nitre paper 
under the nose may do good (F. 51). 

In Interval. — Change of air from town to country, 
or vice versa, may be tried. Avoidance of overeating 
and attention to bowels are necessary. Tonic and 
antispasmodic remedies may be given, and iodide of 
potass has been highly recommended, alone or with 
expectorants (F. 5, 46). 

Pneumonia. 

Acute inflammation of the substance of the lung 
is best recognized, probably, from its clinical history. 



PNEUMONIA. 123 

A person catches cold, as the saving is. The cold 
settles in his chest. There is also feverishness 3 pre- 
ceded by shivering, and accompanied by gastric dis- 
order, and sometimes by jaundice. Then the breath- 
ing becomes accelerated, although not laborious, and 
there is cough, this cough causing pain, which is 
referred to the chest, and, as a rule, to that particular 
part of it which is affected. After a varying interval, 
the cough, which at first was hard, becomes softer, and 
a tough tenacious sputum is expectorated. This 
sputum is considered, and justly considered, character- 
istic of the disease. It is thick, adherent, glairy, 
sticking to the sides of the vessel, and through part 
of it a prune-juice color is observed; or what is more 
often termed the rusty sputum of pneumonia, which a 
student of mine once likened to badly mixed Gregory's 
mixture. The temperature, in accordance with the 
fever, is necessarily increased. The fever is usually 
intense, and may have a very high temperature (up to 
105°); or there may be typhoid symptoms, with de- 
bility, dry tongue, or delirium — so much so as often 
to be mistaken for typhus fever. Pulse frequent, and 
hard at first. A herpetic eruption frequently appears 
on the lips or nostrils about the acme of the fever. 
Such are the general outward signs of pneumonia. 
What is going on inside? In answer to this it may 
be stated that the disease has been divided into three 
stages, which it is well to be familiar with, although 
it is absurd to suppose that they follow one another 
with mathematical precision. In the first stage, if an 
opportunity was afforded of examining the organ at- 



124 DISEASES OF RESPIRATORY ORGANS. 

tacked with inflammation, the characteristic appear- 
ance of the part involved would be redness, with a 
quantity of red frothy serum escaping on section. 
The elasticity and sponginess of the lung is diminished, 
but it still will float in water. The vesicles contain 
fluid and air, hence fine crepitation is heard by the 
stethoscope. In the second stage the redness has 
yielded to solidification. The part affected has a 
thick heavy consistence. It no longer crepitates when 
pressed, and if thrown into water it sinks. Pressed 
between finger and thumb it breaks down, and from 
the appearance being like that of liver-tissue it has 
been termed "red hepatization." Here the fluid in 
the vesicles has coagulated. In the third stage reso- 
lution is taking place in the majority of cases, and the 
lung is coming back to its primary condition. When 
cut into, a great quantity of reddish or grayish fluid 
oozes out. Hence some call this " gray hepatization." 
This stage may, however, be carried farther into diffuse 
suppuration, and sometimes, though rarely, into ab- 
scesses and gangrene. 

The change from the first to the second stage goes 
on rapidly, twenty-four hours or even less being suf- 
ficient. It must also be remembered that you may 
have one part of the lung in the first, another in the 
second, and another in the third stage, so that the 
auscultatory phenomena, which come now to be con- 
sidered, will be found to vary at different sites. On 
applying the stethoscope over an inflamed lung, the 
healthy vesicular sound may in part be heard, with 
the addition of minute crepitation during inspiration. 



PNEUMONIA. 125 

AY hat is this due to ? Very probably it is formed in the 
minute spaces of the bronchial terminations and pul- 
monary vesicles; the sound is best realized by rubbing 
a lock of hair in the immediate vicinity of the ear. 

In the second stage, over the part where the lung 
has become dense and solid, neither the vesicular 
murmurs nor the minute crepitation are heard, but 
there is a something else probably, viz., bronchial 
respiration or tubular breathing. This is due to the 
fact that there is entering the condensed mass a per- 
meable bronchus, and the sound is conveyed along 
the solid conducting medium. So, also, there may be 
no bronchial respiration, and no breath-sounds at all 
heard, because the bronchi may be filled up with ac- 
cumulated secretion. Sometimes this may be set free 
by a cough, and the bronchial respiration may be 
established. Ask the person to speak while the steth- 
oscope is applied over the site of the solidified lung, 
and the voice-sounds will be conducted to the ear in 
an intensified manner, and hence the term "bron- 
chophony." Similarly the vocal fremitus w T ill be in- 
creased. On percussing the same part, it can also be 
easily understood distinct dulness will be elicited. It 
is in this stage also that we hear "cegophony," or 
bleating sound of voice, as heard by the stethoscope. 

In the third stage moist sounds are detected, for 
the lung is permitting the air again to enter. It is 
the first stage on a larger and coarser scale, because 
the crepitations are heard both during inspiration and 
expiration. It has been termed the crepitatio redux, 
and it is usually a happy sign in pneumonia, because 

11 



126 DISEASES OF RESPIRATORY ORGANS. 

it indicates that the lung is returning to its duty, per- 
mitting the air to enter its wonted seat. It does not 
come on at once, neither does it invade the whole lung 
at once, and at last, as health is established, it is re- 
placed by the healthy vesicular murmur, if resolution 
has been thoroughly progressing. 

In pneumonia the right lung is more frequently 
attacked than the left, and the site of the inflamma- 
tion is at the base, hence the back and not the front 
is the proper place for hearing the phenomena indi- 
cated. Pneumonia is sometimes double. If it is not, 
the healthy lung, requiring to act with increased force, 
renders the respiration "puerile." 

Should the inflammation end in gangrene, there 
will be an intense fetid smell of the breath, great 
prostration, dyspnoea, and hectic fever; and a fatal 
result unless the part involved is very small. Gan- 
grene may also result from obstruction of vessels, from 
embolism, various septic poisons, and, it is also said, 
from nervous influences. The urine in pneumonia 
during the stage of hepatization shows a marked 
diminution in chlorides. It is frequently scanty, high- 
colored, and tends to deposit urates. The average 
duration of the disease in uncomplicated cases is four- 
teen days, when complicated about twenty-one. 

A certain amount of bronchitis must always accom- 
pany acute pneumonia; very often also pleurisy, when 
the disease is termed pleuro-pneumonia. 

It is necessary to mention two other varieties of 
pneumonia, "catarrhal" and "interstitial." In catar- 
rhal pneumonia the inflammation is limited to single 



PNEUMONIA. 127 

lobules scattered more or less over the lung-substance 
in patches, and varying in size from a hemp-seed to 
an egg. It is always associated with, generally pre- 
ceded by, inflammation of the smaller bronchi, and 
in the great majority of cases occurs in lungs which 
are the seat of pulmonary collapse; a bronchial tube 
becomes obstructed, collapse of the air- vesicles beyond 
the obstruction takes place, and subsequently catar- 
rhal pneumonia is developed with rapid cell-formation 
in the collapsed lobule. It is essentially a disease of 
childhood, although it may occur in adults in connec- 
tion with pulmonary haemorrhage, pyaemia, or other 
affections. Its distinguishing characteristics, in addi- 
tion to those mentioned, are its high temperature, its 
affecting usually both lungs, its being preceded by 
bronchitis, and by the absence of a distinct chill or 
rusty expectoration. 

H Interstitial pneumonia," by some called fibroid 
pneumonia, is rarely a primary affection. The con- 
nective tissue of the lung becomes increased and 
hardened, the calibre of the air-cells is diminised, so 
that a lung, which is the seat of fully developed fibroid 
pneumonia, is solid and hard to the touch, and when 
cut it presents a smooth shining appearance, and gives 
a creaking sound under the knife. 

Prognosis. — Pneumonia occurring in the young or 
very old is attended with great danger. An unfavor- 
able prognosis mast also be given when it is double, 
when the temperature is above 104° Fahr., and when 
the patient has been addicted to drinking habits, and 
becomes delirious in the course of the disease. Al- 



128 DISEASES OF RESPIRATORY ORGANS. 

though the pneumonia, per se, may terminate favora- 
bly, yet through its not resolving properly, or other 
circumstances, phthisis may supervene. In acute 
catarrhal pneumonia the prognosis depends entirely on 
the circumstances attending the development; occur- 
ring with measles or hooping-cough the prognosis is 
favorable. With scarlatina having a temperature 
above 105° it is unfavorable, especially if there is 
also a feeble pulse and a tendency to coma. In in- 
terstitial pneumonia the prognosis as to time is good, 
as people with it may live for many years, and suffer 
only from dyspnoea. Any intercurrent affection will, 
however, have a direct influence on the prognosis of 
a disease which can scarcely be regarded as an inde- 
pendent affection. 

Treatment — Bleeding, once so much in vogue in 
pneumonia, has now been practically abandoned. 
Sometimes, however, leeches are useful if the case is 
seen early and the patient is young and plethoric. I 
have usually found the antimonial treatment the best. 
Thus I give 

R. Vin. antimon., .... ^ss. 
Sp. chloroform., .... gij. 
Aqua, gvj. M. 

A tablespoonful every two hours. In the course of 
twenty-four hours the pulse is diminished in volume, 
the temperature decreased, and the body is bathed in 
perspiration. The expectoration also becomes freer. 
The same mixture is continued for the next two or 
three days, but instead of every two hours it is taken 



PLEURISY. 129 

every four hours. Then it may be stopped, and 
ammonia and bark substituted. The advisability of 
giving stimulants must be judged of by the individual 
peculiarities of the case. If the patient is a broken- 
down and dissipated man, or has been accustomed to 
take them freely, the necessity for their administration 
is indicated from the first. In other cases common 
sense and prudence must guide the practitioner. 

Locally, hot linseed-meal poultices ought to be ap- 
plied and carefully attended to. The temperature of 
the room should be kept uniformly at 60° Fahr., and 
beef tea, given at regular intervals, should form an 
essential part of the dietary. 

Cold bathing or cold applications to the chest have 
found considerable favor in Germany. In addition 
to the general treatment laid down in acute bron- 
chitis, Dr. Flint strongly advises sulphate of quinine 
in full doses as an antipyretic. 

Pleurisy. 

Pleurisy was the designation given at one time to 
every pain connected with the chest, but now it is 
exclusively applied to inflammation of the serous mem- 
brane lining the walls of the thorax and investing the 
lungs. It may thus be either single or double, accord- 
ing as one or both sides are affected. It may also be 
either acute or chronic. 

Symptoms. — In acute pleurisy the attack is usually 
sudden, and there may be no premonitory chill, as in 
pneumonia. Pain is, however, generally felt acute and 



130 DISEASES OF RESPIRATORY ORGANS. 

lancinating, chiefly in the mammary region, and is in- 
creased by cough and inspiration. On account of the 
pain the respiration is voluntarily impeded. The 
cough is short and dry. These local symptoms are 
attended with headache, anxious countenance, hot skin, 
and rapid pulse. The temperature does not rise so 
high as in pneumonia, nor decline so rapidly, but 
tends to fluctuate. 

In the early stages, if the stethoscope be applied to 
the place where the pain is felt, the opposed pleural 
surfaces are heard grating against one another, and 
producing what is termed " the friction-sound." 
This sound only lasts a short time, for, should reso- 
lution have occurred, it ceases, and the investing 
membranes glide over one another as in health ; or 
adhesions may have formed between them ; or, as 
most frequently happens, an effusion of serum has 
taken place into the cavity. This serum again- may 
degenerate into pus, constituting what is termed " em- 
pyema," and this pus may seek an exit either inter- 
nally or externally. If internally, an opening is made 
into the same lung through the pulmonary pleura, and 
the matter is evacuated by expectoration ; or it may 
make its way externally through an intercostal space, 
and usually at the most dependent part. If the 
opening thus formed does not close, we have what is 
termed bronchial fistula if the opening is internal, or 
parietal fistula if external. In this way air may reach 
the pleural cavity, and thus we have pneumothorax, 
or if pus as well, hydropneumothorax. 

The effused matter, consisting of serum, or serum 



PLEURISY. 131 

degenerated into pus, gives well-marked indications of 
its presence. On percussion we find dulness corre- 
sponding to the extent of the effusion, and this dulness 
may be complete or partial according as the fluid fills 
the whole or only part of the pleura. The dulness, 
also, if the effusion is partial, will vary with the posi- 
tion of the patient, the fluid gravitating to the most 
dependent part, except where the fluid is bounded by 
adhesions. If, however, we find a very sharp fluid- 
level on the patient changing his position, we have 
probably air and fluid to deal with, and it is the air 
which gravitates. 

The lung is pressed back against the vertebral 
column, and if this compression is so complete as to 
prevent any air entering it, on auscultation we can 
hear no breath-sounds at all. If, however, we listen 
at the back, viz., at the part where the lung is ad- 
hering, we may detect increased resonance and bron- 
chial breathing; the bronchial or tubular breathing 
being like that of pneumonia, only softer to the ear 
and more superficial. Sometimes, when the patient 
speaks, the voice appears faint, distant, and trem- 
bling, like the bleating of a goat; it is then termed 
oegophony. 

The patient lies on his back or on the affected side 
if the pleurisy is single and the effusion great. The 
effusion, if great, may cause considerable displacement 
of organs. Thus the diaphragm may be depressed 
and the liver displaced downwards if the effusion is 
on the right side. In extreme cases on the left side 
the heart may be so shifted as to be seen beating on 



132 DISEASES OF RESPIRATORY ORGANS. 

the opposite side. The unaffected lung in single 
pleurisy is thrown into increased activity, and the 
sounds becoming more distinct occasion what is 
termed puerile breathing. The intercostal spaces may 
also be flattened or even bulged out, while the inter- 
costal muscles do not rise and fall as in the healthy 
state. The measurement of the affected side will also 
show an increase as compared with the sound one. 

Duration. — This varies ; sometimes amounting to 
five or six days, sometimes to as many weeks. 

Termination. — The effusion may never have become 
purulent, but may be absorbed, as indicated by a grad-^ 
ual diminution of the dulness, and if there are no 
adhesions the lung will resume its natural size and 
functions. If it is bound down by adhesions w T e may 
find that it will not proportionately expand, but shrink 
in comparison with the other side; or empyema and 
hectic fever may result; or there may be an aggrava- 
tion of the symptoms, swelling of the hands, dyspnoea, 
and death ; or the disease may pass into the chronic 
state. 

Varieties. — Usually pleurisy is single, but the dis- 
ease, although primarily affecting one side, may spread 
to the other, constituting double pleurisy. Sometimes 
there is little fever, little pain, no dyspnoea, and yet 
an extensive pleuritic effusion — latent pleurisy. Dia- 
phragmatic pleurisy is characterized by pain in the 
hypochondriac region reflected to the clavicles, great 
dyspnoea, cough, intense fever, and vomiting. 

Diagnosis. — Pneumonia and pleurisy have certain 
things in common, viz., pain in the side, fever, dyspnoea, 



PLEURISY. 133 

oppression, cough, and dulness on percussion. The 
dulness in pleurisy is, however, more complete, the 
elasticity of the lung being more fully lost, and in ad- 
dition there is no fine crepitation and no rusty sputum 
as in pneumonia. Intercostal neuralgia may simulate 
the first stage of pleurisy, but is distinguished from it 
by the pain not being aggravated by breathing, and 
by the absence of friction-murmur and fever. 

Prognosis. — Favorable if single and primary, un- 
favorable if the effusion becomes purulent. If sec- 
ondary to other diseases, it may so complicate matters 
as to be the immediate cause of death. As will be 
seen from the foregoing remarks, the pathology of 
pleurisy may be shortly stated thus: 

1. Some redness of the pleural surfaces. 

2. Exudation partly serous and partly fibrous, the 
fibrin being deposited on the inflamed surfaces; and 
as inflammation goes on this fibrin is replaced from 
below upwards by an inflammatory growth compara- 
ble to granulation-tissue. 

3. The fluid may be absorbed, and thus the two 
granulating surfaces coalesce, obliterating the cavity. 

4. The fluid may increase and degenerate into pus, 
as previously noted. 

The treatment most consistent with the sketch of 
pleurisy given seems to be this: If the case is seen 
'in the early friction-stage, the application of leeches 
to the seat of pain, followed by hot poultices and the 
administration of a purgative. The latter to be suc- 
ceeded by a soothing expectorant mixture (F. 43). 
Opium hypodermically, or by the mouth, is of much 



134 DISEASES OF RESPIRATORY ORGANS. 

benefit, especially if combined with calomel. Control- 
ling the movements of the affected side by straps of 
sticking plaster has been found useful in preventing 
effusion. If effusion has already taken place, then it 
is necessary to promote absorption. Of the remedies 
most useful for this, special mention must be made of 
a pill containing squill, digitalis, and mercury, given 
thrice daily (F. 36). This should be followed by the 
iodide of potassium, with rest in bed, nourishing diet, 
wine, and the local applications of small blisters, or 
the unguent, iod. hydrarg. (F. 5). 

Should the effusion not be removed by these means, 
or should it have become purulent, as indicated by 
hectic fever and sweats, paracentesis by the pneumatic 
aspirator should be performed. The site selected for 
the operation is at the inferior angle of the scapula of 
the side affected, and the fluid should be drawn away 
rather by repeated operations at intervals of a day or 
days than all at once. 

Chronic Pleurisy. 

As in simple pleurisy the pleura is full of fluid to 
a greater or less degree, but this fluid is milky or 
purulent, and often exists w T ith a pulmonary fistula. 
If the pleurisy be double it is often associated with 
tubercles. 

Symptoms. — As in acute pleurisy, after exudation 
there is absence of thoracic vibration, complete dulness, 
and loss of the respiratory murmur, which may be 
replaced by tubular bronchial breathing. The side 



CHRONIC PLEURISY. 135 

affected remains immovable, the intercostal spaces are 
filled up, while any other position than lying on the 
back, or the side affected, is impossible. When chronic 
pleurisy is primitive, L e., does not follow on an acute 
affection, it does not announce itself by any local pain, 
the fever, if any, is irregular, with little or no dyspnoea. 
In fact, the pleura may sometimes be full of fluid 
without the patient being conscious of this. After 
this mode of invasion, tuberculosis is apt to set in with 
weakness and enfeebled digestion, followed by hectic 
fever and night-sweats. 

Treatment should be tonic, — cod-liver oil, syrup of 
the iodide of iron, and good nourishing soup and beef 
tea. 

Should there be no indication of tuberculosis or 
cancer, should the effusion seriously endanger the 
patient's life by suffocation, and should it fail to be 
removed by the means mentioned, or by absorbent or 
diuretic treatment, it is advisable to perform para- 
centesis (F. 35, 36, 37). 

Addenda to Chronic Pleurisy. — The condition termed 
pneumothorax may here be briefly alluded to. In- 
juries may lead directly to this, as from fractured ribs 
or blows, but in the great majority of cases the air is 
admitted as the result of the bursting of a small cavity 
into the pleura in the progress of phthisis. Sudden 
severe pain, faintness, and dyspnoea characterize this 
occurrence at first, and afterwards the face and lips 
become blue and swollen. The percussion-note is 
abnormally clear on the affected side, or dull; the 
intercostal spaces are bulged out, and the respiratory 



136 DISEASES OF RESPIRATORY ORGANS. 

sounds, if not entirely absent, are either greatly di- 
minished or have an amphoric quality superadded. 
As there is generally fluid with the air, it may be 
detected at the base of the pleura by dulness on per- 
cussion, and by a splashing sound being sometimes 
produced when the patient is shaken. Fluid and air 
being both present, the condition is known as " hydro- 
pneumothorax." 

As the consequence of disease of the heart, kidney, 
or liver, obstructing the circulation, there may be a 
passive effusion of serum into both pleural cavities, 
and the condition termed " hydrothorax " is established. 
It is not a disease of the thorax per se, but simply 
marks the advance of the general dropsy to the lungs. 



Phthisis, Pulmonary Consumption, 

Is the most fatal and most common disease to which 
the human race is liable ; it may occur in any country, 
and may attack either sex at any age. It may be 
hereditary or acquired, and may run an acute or 
chronic course. Acute phthisis is, however, rare. 

Phthisis (chronic), as we generally observe it, is 
shown by certain general and local symptoms. 

The general symptoms are first dyspeptic: want of 
appetite, a faulty digestion, a marked aversion to all 
forms of fatty food, may for some time precede the 
cough, which is at first dry, and most severe at night 
or early morning, but is afterwards accompanied with 
a clear, sticky expectoration, or it may be tinged with 
streaks or dots of blood. If the expectoration of 



PHTHISIS, PULMONARY CONSUMPTION. 137 

blood is abundant, vomiting accompanies the cough ; 
hence the term "vomiting of blood " so often employed 
by patients. In inquiring into the character of the 
blood it is necessary to remember that if it proceeds 
from the lungs, the succeeding coughs will generally 
bring up portions of blood which remain behind; the 
color becoming darker and darker, and finally turning 
to a dirty brownish-red. If from the stomach, the 
blood comes away by a single act of vomiting, and 
then follow black-colored discharges from the bowels. 
There is no fixed pain, but often a dull, varying, 
aching feeling between the shoulders or below the 
clavicles. Exertion, such as walking quickly, going 
upstairs, occasions dyspnoea, while hurried breathing 
is a constant symptom. Loss of weight and emacia- 
tion from the faulty digestion, or from the accom- 
panying fever, as evidenced by increased tempera- 
ture and quickened pulse, form valuable diagnostic 
signs. 

Sometimes a red line is seen on the gums, and the 
fingers are often clubshaped and the nails curved. 

Some, if not all, of these symptoms are found in 
the first stage of phthisis, and accompanying these, 
and evidencing the existence of the tubercular deposit 
in the lungs, are marked local symptoms. The deposit 
affects, as a rule, the apex of one lung at first, and 
on percussion in the supra-spinous or supra-clavicular 
region, want of elasticity is detected, or actual dulness. 
The expiration is prolonged, and accompanying the 
inspiration a feebleness or jerking is heard, or dry 
clicking. When the exudation has become more 



138 DISEASES OF RESPIRATORY ORGANS. 

marked, and has set up more pulmonary irritation, 
localized evidence of this is shown by subcrepitant 
bubbling sounds, or by bronchial or tubular breathing. 
It should, however, be borne in mind that phthisis 
may have taken perfect hold of the system, and yet 
there may be an absence of physical signs, or only the 
slightest indication of them. In such cases the ther- 
mometer is of great service, as it will indicate an in- 
crease of the evening temperature over the morniug to 
a greater or less extent. 

In the second stage, with which, for convenience of 
description, the third or last stage is included, we find 
the general symptoms to have markedly increased in 
severity. There is distinct flattening above and be- 
low the clavicles of one or both sides. The fever is 
more pronounced, and hectic in its type. The system 
is further weakened by profuse night-sweats and diar- 
rhoea. The cough is frequent and irritable, often 
giving rise to vomiting ; the appetite capricious, and 
digestion greatly impaired. The expectoration is thick 
yellow, sinking in a kind of thin glairy liquid, pellet- 
shaped, or from its resemblance to a coin called num- 
mular ; later on it loses this character, and becomes 
distinctly purulent, sometimes having a greenish color 
and most offensive odor. 

Should a fatal issue result, as usually happens in 
this stage, the exhaustion becomes more profound, the 
night-sweats more severe, and finally, swelling of the 
feet and ankles is often observed. 

The tubercles formed in the first stage have softened 
and broken down, leaving cavities. The layer of lung 



PHTHISIS, PULMONARY CONSUMPTION. 139 

forming the wall of the cavity or cavities is usually 
thick and solid. Hence, on percussion, the sound is 
dull, or if there is a free communication with the open 
bronchi and mouth, there is a cracked-pot sound 
(bruit de pot fele). 



Fig. 5. 




Section of lung, showing cavities. 

On auscultation gurgling is heard, caused by the air 
bubbling through liquid. Should the cavity be dry 
and hollow, " cavernous or amphoric respiration " will 
be present. These sounds may also often be combined 
if the cavity contains fluid at its lower part, while 
above it is to a great extent dry. The vocal reson- 
ance indicates " bronchophony " or well-marked " pec- 
toriloquy/' 

Frequently a murmur is heard below the clavicles, 
especially on the left side, following the first sound of 
the heart, and is presumed to be due to adhesion at 



140 DISEASES OF RESPIRATORY ORGANS. 

the apex of the lung. The shrinking thus occasioned 
produces a bending, an alteration in the direction of 
the artery (subclavian), and the blood flowing through 
the narrowed part gives rise to the murmur. 

The elastic fibres of the lung-tissue can at times be 
detected in the sputa by mixing them with an equal 
quantity of caustic soda in distilled water, 18 : 100. 
Boil the mixture, frequently stirring, then add three 
or four times its bulk of water, and allow it to stand 
in a conical glass. The deposit contains the elastic 
fibres. 

Acute Phthisis 

Is a rare disease, and runs a rapid course. ' It seems 
dependent on tubercular degeneration following catar- 
rhal pneumonia; the pneumonic consolidation, instead 
of undergoing resolution, breaks down into soft cheesy 
matter, with the formation of cavities of various sizes, 
at times all oyer the chest. 

It is attended with a sudden onset, shivering fol- 
lowed by a high fever, pain, cough, dyspnoea, profuse 
sweatings, rapidly increasing weakness, and prostration. 
The pulmonary mischief is evidenced by hurried 
breathing, and small and large crepitations, not local- 
ized but general. 

In the only two cases I have seen death occurred in 
less than five weeks. 

Treatment — The general treatment is indicated 
under tuberculosis. With regard to other remedies, 
cod-liver oil has deservedly been the sheet-anchor of 
the profession for many years. It affords the greatest 



ACUTE PHTHISIS. 141 

amount of nourishment in the smallest form, and 
should be commenced in teaspoonful doses, at first 
mixed with limewater, and gradually increased. The 
oil may also be rubbed externally, especially if the 
stomach cannot digest it. Glycerin can sometimes be 
taken with advantage in dessert or tablespoonful doses 
thrice daily, either alone or with the syrup of the 
iodide of iron in a bitter infusion. Pancreatic emul- 
sion has by some been considered beneficial. Counter- 
irritants, as croton oil or iodine paint, may also be 
employed over the front of the chest. 

It is better to allay the cough with inhalants than 
cough mixtures. The hop inhalation can be specially 
recommended (F. 52). 

Opium or some of its preparations forms the essen- 
tial ingredient in all useful cough mixtures, and must 
be given when it would be cruel and impossible to 
dispense with these (F. 71). The injection of ergotin 
is to be recommended in severe hemoptysis, with 
gallic acid internally (F. 19), ice cloths over the chest, 
and the sucking of ice. To control the diarrhoea 
chlorodyne is useful. And to prevent sweating the 
hypophosphite of lime or the injection of atropia is 
highly serviceable. I have seen much benefit follow- 
ing the use of the hypophosphites in the early stages 
of hereditary phthisis (F. 82). 

Alcohol may be given freelv in all stages of the 
disease. If the case is not too far advanced, and the 
patient can afford it, a sea voyage should be tried ; 
and, if circumstances admit, a residence for some time 



142 DISEASES OF RESPIRATORY ORGANS. 

in a warm and equable climate, such as Torquay, 
Hastings, Mentone, Nice, Algiers, or Madeira. 

Cancer of the Lung 

Is usually of the medullary form, and originates 
from the bronchial glands — thence invading the sub- 
stance of one or both lungs. It may, however, be 
primary. The symptoms are obscure — the more prom- 
inent being dulness on percussion, dyspnoea, tubular 
respiration, and the expectoration of sputum of "red 
currant jelly " character and consistence. Rapid ema- 
ciation ensues, and ultimately death by exhaustion, 
through the malignant nature of the disease, and from 
its involving by pressure nerves, bloodvessels, and 
other structures. Its course is rapid, the mean dura- 
tion being 13.2 months. 

Angina Pectoris. 

The introduction of this term into medical nomen- 
clature is due to Dr. Heberden, who in 1768 first 
described the disease, and stated that the sense of 
strangling and anxiety with which it is attended may 
make it not improper to call it angina pectoris (anguish 
of the breast). It is a rare disease. 

Etiology. — Some consider it merely neuralgic, com- 
mencing for the most part in the pneumogastric nerve, 
and spreadfng in different directions. Militating 
against this theory is the fact that it seems brought 
about by what disturbs the heart's action, viz., mental 
emotion and bodily exertions, and further, that it is 



ANGINA PECTORIS. 143 

so often suddenly fatal. Dr. Jenner believes it due to 
ossification of the coronary arteries, disordering the 
nutrition of the organ. This does not, however, ac- 
count for the sudden pain. Generally speaking, it 
may be said to be essentially connected with fatty de- 
generation, ossification of the coronary arteries, or 
some valvular disease of the heart. 

Symptoms. — The attack is sudden and without warn- 
ing, occurring sometimes when walking quickly up a 
hill or after early breakfast. The pain is referred to 
the cardiac region, and is intense in its character. It 
may radiate from the heart as its central origin, to the 
neck, back, left shoulder, and arm. The suffocating 
feeling with which it is accompanied gives rise to the 
fear of impending death. The countenance is pale 
and covered with sweat; the pulse feeble, small, and 
fluttering ; while consciousness is unimpaired. 

Fortunately the attack does not last long, gener- 
ally only a few seconds, but it may be prolonged even 
an hour. It is paroxysmal in its character, and may 
be evoked by unknown exciting causes. It is a dis- 
ease of middle life or advanced age, and is more com- 
mon in men than women. 

The prognosis is necessarily grave, and sooner or 
later death ensues in the course of a paroxysm. 

Treatment. — During the spasm, externally, mustard 
foot-baths, sinapisms to the back, or hot fomentations. 
Internally, give brandy, or a mixture of sp. amnion, 
aromat, sp. chloroform, and acid hydrocyan. dil. (F. 
13). The inhalation of chloroform, or nitrite of amyl, 
is strongly recommended. 



144 DISEASES OF CIRCULATORY ORGANS. 

The prophylactic treatment consists in a tranquil 
life, moderate diet, abstinence from wine and spirits, 
and the wearing of flannels, no constriction being 
placed about the abdomen. As the attacks often occur 
while walking against the wind or ascending a moun- 
tain, common sense and prudence interdict such ex- 
ercises. 

Hypertrophy of the Heart. 

To understand what is meant by the term hypertro- 
phy of the heart, it is necessary to have some definite 
idea of the size of the organ in health, and also of the 
relative thickness of the walls of its different chambers. 
The size of the heart, all authorities seem to agree, is, 
in health, about the same dimensions as the closed 
fist, and it weighs 8 to 10 ounces. The left side of 
the heart has to do more active work than the right, 
and nature has accordingly provided it with increased 
thickness of the muscular tissue to accomplish this. 
The relative thickness is as follows: The right side 
is to the left as two to five; or in other words, and 
generally, the thickness of the left ventricular wall 
more than doubles that of the right. 

Hypertrophy of the heart is therefore more fre- 
quently found in the left side of the organ, or that 
side of the pump which has the most work to do. 

This hypertrophy may be of two kinds. In the - 
first there is simple enlargement of the muscular walls 
without dilatation of the corresponding chamber. 

In the second, not merely are the walls thickened, 
but the chamber is also increased in size. The first 



HYPERTROPHY OF THE HEART. 145 

is termed simple or passive, the latter active or eccen- 
tric. The first is rare, the second frequent. Dilata- 
tion and hypertrophy thus most frequently go together, 
and the reason for this is obvious if we look at what 
is the cause of hypertrophy. In nineteen cases out of 
twenty there is some obstacle to the transit of blood to 
or from the organ. This obstacle may be in the heart 
itself, or may be due to its being pushed from its ac- 
customed seat by disease of other organs, — such as 
pleurisy. The former cause is the more common. 
Thus, if the aortic valves, which act as sentinels to 
guard and guide the blood from the ventricles, be- 
come incompetent, allowing the blood to flow back 
again, or obstructed, not permitting it to get properly 
out of the chamber, hypertrophy must result. The 
heart has to put on increased force to overcome the 
obstacle, and has to acquire increased space to contain 
the greater quantity now in the chamber. If the 
mitral valve is diseased there will be an increased 
quantity of blood within the left auricle, and hence 
the chamber must be larger. The auricular action is 
not, however, strong, like the ventricular, and, as 
there is not so much increase of power needed, auric- 
ular dilatation often exists without hypertrophy. 

On the right side of the heart we find increased 
size and thickness of the right ventricle, where there 
is some obstacle or too great patency in the pulmo- 
nary or tricuspid valves, or some hindrance in the 
diseased state of the lungs to the proper circulation of 
the blood, as from emphysema. 

Symptoms. — In general the symptoms are developed 



146 DISEASES OF CIRCULATORY ORGANS. 

slowly. They may be broadly enumerated as follows : 
Palpitation, dyspnoea, pain localized about the heart, 
and inability for active exertion, such as walking, run- 
ning, or going upstairs quickly. The character of 
the pulse is usually strong, powerful, jerking; but it 
varies with varying causes. 

On percussion the area of cardiac dulness is found 
to be increased. The direction of the increased dul- 
ness varies according to the part of the heart affected. 
If it be the left ventricle the extension will be down- 
wards and to the left, giving an elongated shape; 
while, if the right ventricle be hypertrophied, it comes 
to form the apex, and thus the outline is square, and 
the dulness extended to the right. There is a sensi- 
ble and very distinct heaving impulse communicated 
to the hand or the stethoscope. The heart-sounds 
are heard over a largely increased surface, and the 
apex-beat is removed from its place. Further, if the 
hypertrophy be simple, the first sound is obscure and 
muffled at the apex. If there is hypertrophy and di- 
latation, the first sound is loud, full, and pronounced; 
while, should there be valvular disease, murmurs will 
be heard, varying as to site and peculiarities with the 
valve implicated. 

Treatment must be guided by the state of the patient. 
If of full and plethoric habit, rich food should be 
avoided, also all alcoholic stimulants, and tea and 
coffee. If, on the other hand, of weak and feeble 
frame, nourishing diet and tonic medicines are neces- 
sary. To combat the violent impulse of the heart 



ATROPHY OF THE HEART. 147 

digitalis is useful; while for dyspnoea, sp. chloroform 
or other stimulants must be administered (P. 12). 

Atrophy of t^e Heart. 

In contradistinction to hypertrophy or enlargement 
of the heart, with increase of the muscular substance, 
we sometimes find the heart atrophied or diminished 
in weight. The muscular substance becomes pale, 
soft, and flabby, and easily broken down. The weight 
of the organ may thus be reduced to one-half of what 
it ought to be, and its chambers are small. 

The simple form of atrophy is the result of debili- 
tating disease, such as fever, cancer, marasmus, phthisis, 
or it may be congenital, or the result of disease of 
the vessels which nourish the heart's substance, — the 
coronary arteries. It is thus rather a post-mortem 
appearance than a distinct disease. 

Symptoms. — If there is marked diminution of the 
size of the heart, the area of cardiac dulness will be 
decreased. The smaller quantity of blood contained 
in the cavities, and the feebler contracting power of 
the organ, will render the impulse weak and the heart's 
sounds indistinct. The pulse will also be found to 
be small. There are, however, no certain diagnostic 
signs. 

There is another form of atrophy in which the mus- 
cular texture becomes altered by fatty degeneration. 
The term fatty degeneration does not imply that the 
heart is overloaded with fat, and has on its outside, or 
even dipping in between its muscular fibres, an increase 



148 DISEASES OF CIRCULATORY ORGANS. 

of adipose tissue. This is rather and better termed a 
fatty growth — a something superadded. What is 
meant by the term fatty degeneration of the heart in 
reality is, that the healthy transverse striae and nuclei 
of the muscular substance are transformed into a con- 
geries of oil-globules. The muscular fibres are short, 
easily broken, and some authorities (Dr. Quain) have 
pointed out that there is frequently ossification of the 
coronary arteries. 

Symptoms, — The diagnosis is beset with difficulties, 
the principal symptoms being a feeble action of the 
heart, — 45 to 50, — weakness, giddiness, and sometimes 
faintness. Then there is what was once considered 
diagnostic of this disease, well-marked "arcus senilis," 
due to fatty degeneration of the edges of the cornea. 
Yet it must be remembered we may have fatty degen- 
eration of the heart without the arcus senilis, and vice 
versa. Men are more often attacked than women. It 
comes on at all ages, but most frequently in advanced 
life. The prognosis is unfavorable. 

It will thus be observed that fatty degeneration 
differs from a fatty growth of the heart, the latter being 
usually associated with general obesity, the fat which 
is normally deposited on the heart being abnormally 
increased, especially among the muscular fibres. 

Treatment can only be symptomatic. 

Pericarditis. 

The fibro-serous membrane of the heart is liable to 
inflammation as the result of cold, of renal disease, of 
specific fevers, of wounds by fractured ribs, of the 



PERICARDITIS. 149 

extension of inflammation from lungs or pleura; but, 
in the great majority of cases, pericarditis occurs during 
an attack of rheumatic fever. The female is less sub- 
ject to it than the male, in the proportion of one to 
five. 

The result of this inflammation is the exudation of 
lymph or serum, and in the early stage of the affec- 
tion, supposing we were enabled to open the body, we 
would find, most likely, the membranous sac partly 
filled with some serum, and with a plastic coagulable 
lymph. At a later stage the effusion would be found 
completely to separate the membranes with layers of 
lymph deposited, forming false membranes, while, at 
a still later stage, the effusion may have been absorbed, 
and the two sides become glued together (adherent 
pericardium). 

The deposited lymph we have mentioned, on account 
of the continual movement of the heart, is laid down 
in a somewhat unequal manner, or in layers, just as 
the tide leaves the sand ribbed ; or in some instances 
it is shaggy, like the rough surface of tripe. 

Symjrtoms. — On auscultating at an early stage of 
the disease, before effusion has occurred, a to-and-fro 
friction-sound is detected, from the serous membranes 
not gliding upon each other with the ease and smooth- 
ness of health. Essentially the sound is of a rubbing 
character, and has been compared to the unfolding of 
a crisp banknote, to the rustling of silk, or the creak- 
ing of new boots. As the endocardium, and especially 
the mitral valve, is generally also implicated with the 
pericardium, there is usually a systolic bellows mur- 



150 DISEASES OF CIRCULATORY ORGANS. 

mur which may mask the friction-sound , and it is to 
be remembered that while the systolic murmur is per- 
manent, the to-and-fro friction-sound may not be de- 
tected, and, in any case, does not last long, for the 
patient may die during its continuance, or the effusion 
may be so great as to prevent the membranes rubbing 
on each other, or they become adherent — glued to- 
gether. When effusion has occurred, the dilated peri- 
cardial sac assumes a pyramidal form, with its apex 
upwards towards the second left costal cartilage, its 
base corresponding with the lower edge of the sixth 
rib; consequently dulness will be detected on percus- 
sion over this area, and varying to some extent with 
the position of the patient. If the pericardium becomes 
adherent, the dulness will be that of the normal heart. 

The general symptoms attendant on pericarditis 
vary, and are so insidious as sometimes to attract 
little attention. Pain is referred to the cardiac region, 
and is increased by cough or pressure, or lying on the 
left side. The heart's action is irregular and inter- 
mittent, and this is more apparent after the fatigue of 
speaking, or taking food, or any emotion. Patient 
lies propped up, complaining of headache, with anx- 
ious countenance and difficulty of breathing, and of 
disturbed and restless sleep. This restlessness passes 
into delirium in fatal cases, and is attended also with 
oedema of the lungs and other symptoms of malaera- 
tion of the blood. 

Prognosis. — Pericarditis is a grave malady, yet, 
when occurring in rheumatic fever, it is not so much 
to be dreaded for its immediate as its. after conse- 



ENDOCARDITIS. 151 

quences, in producing endocarditis and leaving* per- 
manent valvular disease. Should it supervene in the 
course of a chronic disease it is generally fatal, the 
prognosis being specially grave in Bright's disease, and 
in cases of copious and rapid effusion. The prognosis 
should be determined rather by the complication than 
the disease itself. 

Treatment. — General bloodletting, once so preva- 
lent, has now been abandoned. The local application 
of leeches does good by easing the pain in the early 
stage of the disease, and should be followed by the 
application of hot linseed-meal poultices, and fomen- 
tations. AVhen effusion has occurred, the object is to 
promote absorption, and for this purpose blisters are 
serviceable. Mercury pushed to salivation "is now 
rarely employed ; combined with squills and digitalis 
it is a diuretic and absorbent, and as such may be 
given (F. 36). Iodide of potassium is also largely 
used (F.- 5). The strength should be supported by 
strong soup, beef tea, with wine and brandy, if these 
do not excite the action of the heart. Stimulation is 
specially necessary in pericarditis occurring in Bright's 
disease or fever. 

Endocarditis. 

By endocarditis is meant an inflammation attacking 
the lining membrane of the heart. It is usually asso- 
ciated, as has been indicated, with pericarditis; yet by 
some authors it is contended that it exists as an inde- 
pendent disease. In any case, we do not often see this 



152 DISEASES OF CIRCULATORY ORGANS. 

endocardial inflammation in its early stage. If we did 
we would observe — 

1st. Increased redness and vascularity. 

2d. The membrane thickened, polished, and smooth. 

3d. Fibrinous vegetations forming and attaching 
themselves to the valves, which are also involved in 
the inflammation. The valves may thus become thick- 
ened or puckered or adhering together, and their 
healthy action is permanently impaired. 

Symptoms. — Endocarditis, occurring as it does in 
the great majority of cases during an attack of acute 
articular rheumatism, Bright's disease, or pyaemia, has 
its symptoms so much masked by the severity of these 
affections that its actual existence is only recognized 
in many cases by the physical signs which it leaves of 
valvular mischief. There may be, however, an indi- 
cation of its existence at the moment — general uneasi- 
ness about the heart, palpitation, restlessness, cold 
sweats, and increased fever. In a variety of endocar- 
ditis an ulcerative destruction of the heart's substance 
occurs, and this form is characterized by typhoid 
symptoms, prostration, and a rapidly fatal issue. 

Treatment is the same as pericarditis. 

Cardiac Murmurs. 

On listening over the cardiac region in health, two 
distinct sounds are heard following each other at regu- 
lar intervals. These sounds have been termed first 
and second, systolic and diastolic, as the one corre- 
sponds to the contraction (systole), the other to the 



CARDIAC MURMURS. 



153 



filling up (diastole) of the ventricles. The first sound 
has its maximum intensity at the apex of the heart; 
the second at the base, or, more accurately, on a level 
with the third rib and a little above and to the right 
of the left nipple, near the left edge of the sternum. 
In determining therefore the state of the heart, it is 



Fig. 6. 




Ventricular svstole. 



necessary first to apply the stethoscope at the apex 
and next at the base on the spots mentioned, and to 
ascertain whether or not a murmur or murmurs exist, 
denoting a variation from the sounds of health, and if 
so, what valve or valves are implicated. In order to 
realize what is to follow it is advisable to leave out of 
account the right side of the heart and to fix the atten- 



154 



DISEASES OF CIRCULATORY ORGANS. 



tion entirely on the left side, and more particularly 
the left ventricle, which has two valves in connection 
with it, — the mitral and the aortic. With the con- 
traction or systole of the ventricle (Fig. 6), the mitral 
valve is closed, to prevent blood flowing back into the 
auricle, and the aortic valves are laid back to allow it 
to go freely away on its circuit. With the filling up 



Fig. 7. 




Ventricular diastole. 



or diastole of the ventricle, the reverse of this happens 
(Fig. 7). The mitral valve opens and the aortic valves 
are closed to prevent the blood flowing back from 
the aorta into the ventricle. If disease has involved 
one or more of these valves, interfering with their 



CARDIAC MURMURS. 155 

healthy action, a murmur or murmurs are occasioned, 
which may be considered regurgitant or obstructive, 
according to rhythm, or the time when they are heard ; 
and thus we may have one or more of four great 
classes of murmurs, viz., mitral regurgitation, mitral 
obstruction, aortic regurgitation, aortic obstruction. 
The further great practical fact may be dogmatized 
thus: Mitral murmurs are heard loudest at the apex; 
aortic murmurs at the base; accordingly, if a murmur 
is heard following the first sound, it may be termed 
generally a ventricular systolic (V. S.) murmur, and 
if loudest at the apex and diminishing or lost at the 
base, it is due to mitral regurgitation; or if loudest at 
base, it is dependent on aortic obstruction. If a mur- 
mur follows the second sound it may be termed gen- 
erally a ventricular diastolic (V. D.) murmur, and as 
indicating its nature, aortic regurgitant. Again, a 
murmur may be heard following neither directly the 
first nor second sound, but immediately preceding the 
first, it may be termed auricular diastolic (A. S.) mur- 
mur or presystolic, or, as more definitely recognizing 
its causation, mitral obstruction. 

Attention to these considerations will enable the 
student generally to detect the nature of the lesion, 
aided as he will be by the state of the pulse, which as 
a rule is soft and compressible in mitral, and hard and 
jerking in aortic disease; and by the pulmonary symp- 
toms, which are more common and urgent in mitral, 
while cerebral symptoms or complications are more 
often associated with aortic disease. I purposely say 
nothing of diseases of the right side of the heart, as 



156 



DISEASES OF CIRCULATORY ORGANS. 



they are rare, and to enter completely into their causa- 
tion would confuse the conception desired to be re- 
tained by the student of a single-chambered organ in 
connection with the subject of heart murmurs. 

The following tables, read, however, in connection, 
with what has been said, can now be understood : 

A. — Mitral obstruction, stenosis, presystolic mur- 
mur, indicates an impediment to the flow of blood from 
the left auricle to the left ventricle. 

Recognized by a purring thrill at apex ; a murmur 
running up to the first sound and loudest at apex ; 
a feeble, often irregular pulse ; difficulty of breathing 
after exertion. 

It occasions sometimes little uneasiness; sometimes 
pulmonary congestion and spitting of blood; some- 
times it terminates in sudden death. 

J5. — Mitral regurgitation, incompetence, an imper- 
fect closure of mitral valve, permitting blood during 
contraction of ventricle to flow back to the auricle. 

Recognized by a blowing murmur following the 
first sound, and heard the loudest at the apex; di- 
minishing towards or inaudible at the base, confirmed 
by its being heard at inferior angle of left scapula; 
pulse feeble and irregular. 

Caused by contraction of segments of valves; by 
dilatation of left ventricle; by irregular contraction 
of papillary muscles. 

Resulting in more or less suffering from congestion 
of lungs, liver, and kidneys; rarely in sudden death. 

C. — Aortic obstruction, stenosis, narrowing of orifice, 



CARDIAC MURMURS. 157 

preventing blood flowing easily from the left ventricle 
into the aorta. 

Recognized by a murmur following the first sound, 
heard loudest at the base, always propagated to the 
vessels of the neck, sometimes with considerable inten- 
sity downwards along the sternum ; pulse small, hard, 
regular. 

Resulting often in little suffering for years, in con- 
sequence of compensating hypertrophy of left ven- 
tricle. 

D. — Aortic regurgitation, incompetence, an imper- 
fect closure of the aortic valves, causing regurgitation. 

Characterized by a murmur following the second 
sound diffused more or less along the whole sternum, 
although perhaps loudest at third right costal cartilage; 
shotty jerking pulse. 

Resulting sometimes in sudden death; sudden 
attacks of dyspnoea and oppression are often promi- 
nent symptoms. 

E. —Tricuspid obstruction rare. 

F. — Tricuspid incompetence, regurgitation, imper- 
fect closure of tricuspid valve. 

Recognized by increased dulness of right side of 
heart; diffused pulsation over the right ventricle; 
murmur with the first sound ; pulsation and fulness 
of jugular veins; dyspnoea and dropsy; generally 
associated with mitral regurgitation or emphysema. 

G. — Pulmonary stenosis rare. 

Pulmonary incompetence also rare; detected by its 
situation over the pulmonary valves by its loudness 
and non-propagation from this spot. 

14 



158 DISEASES OF CIRCULATORY ORGANS. 

It must be remembered that these murmurs are 
frequently combined — the most frequent combination 
being aortic obstruction and regurgitation ; mitral 
obstruction and regurgitation ; various combinations 
of mitral regurgitant and aortic murmurs. These 
murmurs are termed organic murmurs, and are per- 
manent, while another class of murmurs, denominated 
functional, are associated with chlorosis or debility. 
They are heard at the base of the heart and in the 
vessels of the neck, follow the first sound, and may 
disappear under treatment. 

Treatment. — In valvular diseases of the heart of all 
kinds we have to face un fait accompli, and prophy- 
lactic treatment cannot thus be put in force. Post- 
mortem appearances indicate the compensatory efforts 
of nature to overcome the various obstacles to the flow 
of blood. The indications of all treatment, therefore, 
are to advance the development of compensation when 
already in existence, to maintain it as long as possible, 
and to moderate over-compensation. Hence the diet 
should be nourishing, not stimulating, all spirituous 
liquors and much smoking disallowed, and good di- 
gestion promoted by fresh air and cautious exercise. 
The mind should be kept at rest, and the attention 
never unnecessarily attracted to the state of the organ. 
To combat unusual irritability, to promote the nutri- 
tion of the cardiac walls, to render the pauses between 
the heart's contraction longer, digitalis is the sovereign 
remedy, either alone or combined with iron (F. 88). 
It acts as a cardiac tonic, not as a depressor, and its 
use may be continued for the purposes indicated 



THORACIC ANEURISM. 159 

either in the form of the tincture or infusion, for a 
considerable length of time. 

Pain is best relieved by subcutaneous injections of 
morphia ; commencing dropsy by diuretics, such as 
squills and digitalis (F. 35, 37). 

AYhen the heart's action is irregular, the pulse low, 
the urine scanty, and disturbed compensation evident, 
the diuretic effects of digitalis and quinine are highly 
recommended (Rosenstein). 

Palpitation of the Heart 

Expresses increased frequency of cardiac action, ir- 
regularity, suddenness of impulse ; and varying causes 
may originate this, mental excitement, strong tea, 
tobacco, indigestion, exertion, gout. 

As a rule, the symptoms which accompany the pal- 
pitation without organic disease are flushings or pallor 
of the face, ringing in the ears, or some coldness of the 
extremities. The causes being removed, the palpi- 
tation is removed ; yet at times the heart may get 
hypertrophied or dilated through the chronicity of the 
palpitations. 

Thoracic Aneurism. 

There are three chief situations for thoracic aneu- 
risms ; viz., the ascending portion of the aortic arch, 
the transverse part of the arch, or the roots of the 
large vessels arising from the arch. 

Most frequently they spring from the ascending 
arch, and from the convexity rather than the concavity. 

Aneurisms of the arch embraced by pericardium 



160 DISEASES OF CIRCULATORY ORGANS. 

are always small in size, and are usually associated or 
confounded with simple aortic valvular disease. 
When the aneurism is situated beyond the pericardium 
it frequently attains a very large size, displacing the 
lung outwards, especially on the right side, and an- 
teriorly coming in contact with the anterior thoracic 
wall, where it may ultimately form a visible pulsating 
tumor. In the interior of the chest it presses on the 
right lung, and may compress the descending vena 
cava, and involve the right pneumogastric nerve. An 
aneurism in this situation is liable to open externally 
or internally into the pericardium, right pleura, or 
lung itself; an aneurism of the transverse arch spring- 
ing from its convex portion spreads upwards, and to 
the left, pressing upon the manubrium sterni, the 
clavicle and the left upper ribs in the same situation. 
A tumor is thus formed in the region mentioned, 
which sometimes rises from the sternum into the root 
of the neck. If it springs from the posterior surface 
of the transverse portion of the arch, its course is often 
latent. 

Aneurisms of the descending part of the arch are 
rarely to be detected until they have attained a large 
size; although their presence may be suspected by 
dulness, pulsation, murmur, absence of respiration 
over a limited area, with dull aching or burning pain 
over the vertebra. 

General Symptoms. — When the tumor can be de- 
tected externally the diagnosis is easy, but if this is 
not the case the symptoms are obscure, and generally 
speaking consist in cough, dyspnoea, difficulty in 



ABDOMINAL ANEURISM. 161 

swallowing, and pain about the chest and back. The 
cough is audibly brassy in character, and attended with 
a suffocative feeling if one or both recurrent laryngeal 
nerves are implicated; and if the tumor extends 
deeply backwards, pressing on the ganglia and branches 
of the sympathetic, there will be permanent contrac- 
tion of the pupil of the affected side. 

The physical signs are dulness, " bruit," absence 
of respiration, or bronchial respiration from pressure 
on a bronchus. Again, if the transverse part of the 
arch be the seat, the tumor or pulsation may be felt 
by placing the finger deeply in the supra-sternal notch. 
Heart murmurs and pain, or numbness of the arm or 
side, serve to confirm our diagnosis. 

The duration of the disease is uncertain. In thirty 
cases collected by Lebert the disease lasted from one 
year to four years. The disease seems to make more 
rapid progress in young people than in old. The prog- 
nosis is necessarily very unfavorable. 

For treatment, see page 162. 

Abdominal Aneurism. 

Aneurisms of the abdominal aorta are more frequent 
above than below the coeliac axis. They are spindle- 
shaped or saccular (from three to six inches in mean 
diameter), often of very considerable size, the contents 
being as much as ten pounds. They project from the 
anterior surface or sides of the artery, and tend to de- 
velop downwards and to the left more than upwards 
and to the right. 



162 DISEASES OF CIRCULATORY ORGANS. 

Symptoms. — A tumor is usually found to the left, 
just above the navel. On palpation a forcible pulsa- 
tion is perceived, a little after the apex beat, and ac- 
companied with a thrill, and along with this thrill a 
murmur is heard. The murmur may be propagated 
into the iliac and femoral arteries. 

Functional disturbances may also be present in a 
greater or less degree. The most common of these is 
pain in the belly and in the back, corresponding to 
the seat of the tumor. 

There may also be vomiting, diarrhoea, or consti- 
pation. 

The general condition of the patient may remain 
unaltered for some time, or there may be progressive 
debility. Rupture of the aneurism is frequent, giving 
rise to sudden peritonitis ; or sometimes an aneurism 
of this kind may burst into the left pleural cavity. 

Treatment. — The general treatment must be that 
advisable in all forms of cardiac disease, viz., rest, and 
avoidance of all excitement, mental or bodily. Prob- 
ably Tuffnell's method in thoracic as in abdominal 
aneurism is the best; the principle being the giving 
of a spare dry diet, with few liquids, and the enjoining 
of strict and absolute rest in the recumbent position. 
Hence he orders six ounces of milk, two ounces of 
roast meat, and six ounces of bread and butter. By 
this means the blood tends to coagulate in the sac; 
just as water, through which a comparatively stag- 
nant stream flows, affords every opportunity for the 
accumulation of debris on the sides, so in this way, 
at the sides of the aneurismal sac fibrin becomes ac- 



ULCERS OF THE TONGUE. 163 

cumulated in layers, and ultimately is moulded into 
the walls of the sac. 

Of medicinal agents, iodide of potassium, in large 
and increasing doses to the extent of 90 grains daily, 
is held most in repute. This drug has the support of 
eminent English and foreign authorities. The sub- 
cutaneous injection of ergotin has been tried in the 
immediate neighborhood of the tumor twice or thrice 
daily, the object being to diminish the sac by produc- 
ing contraction of its muscular elements. 

Galvano-puncture in some cases has been success- 
ful. Out of twenty-three cases related by Ciniselli, 
five were cured. " The mechanical action of the 
needles is combined with a chemical action produced 
by the electrolytic decomposition of water and of the 
salts of the blood." 

Ulcers of the Tongue. 

Simple ulcers, the result of gastric derangement 
may form on the tip or frsenum of the tongue. Ul- 
cers may be of syphilitic origin, and if so, are usually 
situated at the sides of the tongue and inside of the 
lips. Sometimes syphilis forms oval bald patches, 
without any ulceration. 

Treatment. — If the result of gastric derangement, 
attention to the diet and a 'mild purgative will gener- 
ally effect a cure (F. 8). If of syphilitic origin, then 
the constitutional remedies for that disease must be 
put in force. 



164 STOMATITIS. 

Stomatitis. 

Several forms have been described : catarrhal, fol- 
licular, aphthous, ulcerative, parasitic, gangrenous, 
mercurial. 

Parasitic stomatitis depends on the presence of a 
parasite, Oidium albicans. There is heat and pain in 
the mouth, and the disease is revealed by whitish- 
gray patches, looking like curdled milk. It is pecu- 
liar to young infants, being known by nurses and 
mothers as the thrush. Sometimes it appears in the 
course of phthisis in adults. 

Gangrenous Stomatitis, or Canckum Oris, is 
a rare but dangerous affection, attacking weakly chil- 
dren recovering from measles or other acute diseases. 
The ulceration commences on the mucous membrane 
of the lip or cheek, and spreads to the deeper tissues, 
perforating the skin and destroying the jaw. 

Swelling of the cheek, intense fetor of the breath, 
great salivation, and rapid prostration, with a fatal 
termination, accompany the local changes described. 

Treatment — In all affections of the mouth, chlorate 
of potass seems beneficial, given in five-grain doses to 
an infant of a year old, but increased to twenty or 
thirty in an adult (F. 7). Borax and honey may be 
applied locally in thrush; and in cancrum oris the 
only chance for the child depends on its being put 
under chloroform, and having the part burnt with 
strong nitric acid. The strength must also be sup- 
ported by brandy and beef tea. 



mumps — quinsy. 165 

Mumps, Cynanche Parotidea, 

Is an acute contagious affection of the parotid and 
other salivary glands, the parotid especially being 
much swollen and painful to the touch. It is attended 
with some fever, and difficulty of opening the mouth 
and swallowing. The disease extends over a period 
of four or five days, and terminates in recovery, its 
declension being occasionally marked by swelling of 
the testicles or mammae. 

Quinsy, Cynanche Tonsillaris, 

Is attended with fever, fetid breath, and pain in one 
or both tonsils, shooting along the Eustachian tube 
into the ear. 

The tonsil or tonsils are red and inflamed, the in- 
flammation terminating in resolution or progressing to 
suppuration, with speedy recovery following the dis- 
charge of pus. 

It is caused chiefly by exposure to cold, and is most 
common in youth. 

A form of chronic tonsillitis is not uncommonly 
seen in young and delicate children, where the tonsils 
are enlarged and the voice husky, with occasionally 
deafness. 

Treatment — In mumps a saline mixture and a flan- 
nel bandage over the glands are alone requisite (F. 
66). In quinsy the inhalation of steam and the ap- 
plication of hot linseed-meal poultices hasten resolu- 
tion or promote suppuration. Sulphate of magnesia 



166 DISEASES OF THE (ESOPHAGUS. 

(F. 24) can be recommended. Gaaiacum is by some 
considered a specific (F. 6). In chronic tonsillitis ex- 
cision of part of the gland is sometimes necessary. 

Diseases of the (Esophagus. 

The oesophagus may be the seat of stricture, either 
spasmodic or real, or of cancer. 

The affections are all characterized by one promi- 
nent symptom, difficulty of swallowing, with, in can- 
cer, also great pain, enlargement of the lymphatic 
glands, cough, and husky voice, through pressure on 
the trachea or recurrent laryngeal nerves. Non-can- 
cerous stricture is generally the result of swallowing 
some corrosive poison. 

Treatment can only be palliative, unless in the spas- 
modic stricture of young and hysterical females, when 
the general treatment recommended in hysteria may 
be adopted. 

Dyspepsia. 

The stomach is the natural receptacle of the food 
we eat and the liquid we drink. It starts on equal 
terms with other organs, but its powers of endurance 
are tried more than those of any other organ. Into 
it are thrown the most heterogeneous compounds, and 
it is expected to do its duty satisfactorily, whether we 
lead the life of an anchorite or an epicure ; or if we 
go to neither of these two extremes, if we neither eat 
too plainly nor too abundantly, we may yet try its 
staying powers by the rapidity with which we swallow 



DYSPEPSIA. 167 

our food, or the length of time we allow to elapse be- 
tween meals. 

An organ tried so much naturally rebels, gets out 
gear, and sooner or later dyspepsia or indigestion 
supervenes, and the whole body sympathizes with its 
ailments. The mind becomes clouded, and the temper 
peevish, bodily vigor is impaired, and life is rendered 
not a pleasant holiday, but a sour and angry fact. 
Dyspepsia has many symptoms, and a brief consider- 
ation will be given to the most prominent of these, 
and how they may be met. 

Want of appetite may depend on mental causes, as 
joy, or anger, or anxiety, or it may appear without 
any apparent cause. Common sense must dictate 
how to deal with the former causes, and for the latter, 
an acid or a bitter infusion may be employed (F. 10). 

Nausea and Vomiting, — Xausea after taking food, 
which may or may not terminate in vomiting, some- 
times attracts attention — the vomited matters being 
sour at first, and if long continued mixed with bile. 
To soothe this irritability there are special therapeutic 
remedies, in additiou to careful regulatiou of the quan- 
tity and quality of food, such as creasote and hydro- 
cyanic acid (F. 9). 

Flatulence and Belching. — Flatulence, popularly 
termed " the wind on the stomach," may be due to 
many causes, prominent among which are food fer- 
menting, or the want of an accustomed meal at a cer- 
tain hour. 

It is often relieved by warm carminatives (F. 13), 
and by the injunction of a regulated interval between 



168 DYSPEPSIA. 

meals. If it immediately follows the taking of food, 
pepsin is useful, or rhubarb (F. 91). 

Should belching be accompanied by a rotten-egg 
flavor, showing the evolution of sulphuretted hydrogen 
gas, charcoal biscuits should be ordered, and creasote ; 
if there is also great acidity, sal volatile and carbonate 
of potass (F. 73). 

Pain. — Cullen described two kinds, cardialgia or 
heartburn, and gastrodynia or cramp, or spasm of the 
stomach. For simple heartburn black sugar is effica- 
cious, or eating an apple, or a draught of liquor bis- 
muth and spirit of chloroform, or (F. 11). Gastro- 
dynia, Dr. Abercrombie thought, was due to a loaded 
colon, and hence ordered a brisk purgative, followed 
by carminatives (F. 25, 13). A mustard poultice 
often gives relief. 

Waterbrash, pyrosis, attended with the eructation 
of thin tasteless watery fluid, may be connected with 
organic disease of the stomach, or with the taking of 
some particular kind of food, as oatmeal. Treating it 
simply as a symptom, pulv. kino co. can be recom- 
mended, combined with a watery purgative in the 
morning, as Friedrichshall or Pullria. 

In 1842 John Goodsir discovered in the vomited 
matters of certain patients small flat bodies having a 
rectangular outline, and a somewhat oblong shape, and 
resembling little packets tied lengthwise and across 
with a string, hence he called them sarcinse (bundles). 
They are dependent on fungi, and are symptomatic of 
organic disease by which the stomach is prevented 
from completely emptying itself. Sulphite of soda 



GASTRIC ULCER. 169 

given in 20 to 60 grain doses relieves what probably 
is an always incurable disorder, by the sulphurous acid 
being set free in the stomach. 

Dyspeptics constantly ask, What shall we eat, and 
what shall we drink ? and, although no fixed rules can 
be laid down, the following points are of practical 
importance. 

Mutton is probably the most digestible of all animal 
food, while all cured meats — ham, tongue, sausage — 
are indigestible. Animal food is more easily digested 
than vegetable. While man's organs of digestion ally 
him more to the carnivorous than the granivorous 
race, yet a mixture of animal and vegetable food suits 
the stomach best. Do not press prohibitions as to food 
too far, else you will convert the dyspeptic into a con- 
firmed hypochondriac. 

Interrogate the patient as to his own sensations with 
regard to liquids, as no definite rule can be given. 
Beer agrees with some, sherry or claret with others. 
Many men can be total abstainers with impunity, 
many others cannot, and require whisky or brandy 
with meals. The consideration of the idiosyncrasies 
of each individual case must thus be daily weighed in 
regulating the dietary of the dyspeptic. 

Gastric Ulcer. 

Ulceration of the stomach is by no means an un- 
common affection, and is much more prevalent in 
females than in males. 

Symptoms. — Painful intolerance of food is the chief 



170 GASTRIC ULCER. 

symptom. The pain which is felt at the epigastrium 
varies in intensity, and appears within a quarter of an 
hour after food is taken, being increased by emotions 
or pressure over the umbilical or dorsal regions, ac- 
cording to the situation of the ulcer. Vomiting of 
food in all stages of digestion, with or without blood, 
is a pretty constant symptom. The quantity of blood 
varies greatly, but when present in any quantity it is 
a most important sign. Constipation almost invari- 
ably accompanies gastric ulcer, and the patient has a 
worn-out, low-spirited aspect. Lastly, the failure of 
all remedies and the chronic history help us in form- 
ing our diagnosis. 

The intensity of these symptoms varies more ac- 
cording to the position than size of the ulcers, on 
account of some positions being more exposed to con- 
stant friction than others. If the ulcer be close to 
the pylorus, we may have stricture from spasm of the 
pyloric muscle, and thus the vomited matter will be 
in a sour and fermented state from its long retention 
in the stomach. Again, if the ulceration goes on to 
perforation and no limiting adhesions form, the con- 
tents pass out of the stomach, and give rise to symp- 
toms of acute general peritonitis. 

The course of the disease is very chronic, lasting 
sometimes the greater part of a lifetime. It may 
occur at any age, tending more to cicatrization in the 
old and perforation in the young. * 

This chronic course runs on to one of three termi- 
nations. 

1. After long suffering, sometimes with relapses, 



GASTRIC ULCER. 171 

the patient gets better, owing to the ulcer cicatrizing ; 
still, great care must be observed. This occurs in 
half of the cases. 

2. Sudden death, from shock, owing to its bursting 
into the peritoneum; from peritonitis, or from haemor- 
rhage. 

3. Gradual death, from sheer wearing out. In 
such cases amenorrhoea or phthisis may supervene. 

Pathology. — It is a distinct local lesion. The ulcer 
seems punched out, and the edges may be bevelled off 
or thickened. The size varies from that of a pin's 
head to one-third of the mucous membrane of the 
stomach. It may be of all degrees, from partial re- 
moval of the mucous membrane to perforation, and it 
may be puckered, cicatrized, or healed. The com- 
monest seats are on the anterior or posterior wall, 
near the lesser curvature. If on the anterior wall, 
perforation more readily occurs on account of there 
being no place for limiting adhesions, while, if on the 
posterior, adhesions may take place to the pancreas, 
etc., and thus, although the stomach is actually per- 
forated, the adhesions prevent its contents passing 
into the peritoneum. It is worthy of note that, by 
means of adhesions, a communication may be set up 
between the stomach and colon, and thus fecal mat- 
ters will be vomited with ease, not with difficulty as 
in ordinary stercoraceous vomiting. The nearer the 
ulcer is to the coronary vessels, the greater the ten- 
dency to fatal haemorrhage. 

Treatment. — We have neither prophylactics nor 
specifics. All food should be given in very minute 



172 CANCER OF STOMACH. 

quantities and in liquid form. Hence milk, solution 
of beef, or soups containing white of egg, are most 
useful. In order to get the stomach to retain sufficient 
food, opium should be given by the mouth, so as to 
act as a gastric sedative during digestion. Collections 
of acid matter in the stomach may be prevented by 
alkalies or alkaline saline mineral waters. If vomit- 
ing continues, we must have recourse to bismuth, 
hydrocyanic acid dilute, creasote, or ice, and if all 
these fail, make use in time of nutrient enemata 
(F. 9). When there is hsematemesis, if not severe, 
ice, gallic acid (F. 19), or turpentine, may be tried; 
but if much blood is being vomited, we should try at 
once the subcutaneous injection of ergotin, thus — 

R. Ergotin, gr. xv. 

Alcohol, n^xl. 

Aq. distil., gij. M. 

Fifteen drops a dose. 

Cancer of Stomach. 

Cancer has a partiality for the orifices of the stomach, 
being commonest at the pylorus. When in that situa- 
tion it is usually fungating or villous, of the scirrhous 
type, and may be associated with cancer elsewhere — 
especially of the liver. When at the cardiac orifice 
the cancer ~is always of the epithelial type, and fre- 
quently extends up the oesophagus. * The body of the 
stomach is very rarely affected without the orifices. 

Symptoms. — Vomiting and pairi are pretty constant 
symptoms. When the pylorus is involved the vomited 



CANCER OF STOMACH. 173 

matter is frothy and fermented, containing sarcinse, 
and the pain comes some time after taking food. If 
the cardiac orifice be the seat, the vomited matter con- 
tains blood altered by the secretions (" coffee-grounds 
vomit"), and the pain comes on immediately after 
taking food, and is very lancinating. In either case 
vomited matter may contain cancer elements. 

Loss of appetite, with the general cancerous cachexia, 
are prominent symptoms, the latter being well marked, 
with great emaciation. The physical examination is 
most important. A hard, uneven, immovable tumor 
is felt an inch or two below the liver, to the right side, 
although it may be dragged to the left. When the 
pylorus is affected, the stomach is large and distended. 
The percussion is tympanitic, and hippocratic suc- 
cussion may be developed from the presence of fluid 
food and air. By grasping the stomach, the limit of 
the motion of the fluid, and thus the size of the stom- 
ach, may be seen, as well as an exaggerated peristaltic 
motion giving sometimes an hourglass appearance, 
and beginning at the left hypochondrium. 

The bowels being to a great extent empty, undue 
prominence of the epigastrium is a not uncommon 
sign. 

Duration is important, as it never exceeds two 
years. 

Treatment can only be palliative and supporting. 
Food should be given in small quantities, and — if it 
is pyloric obstruction — of such a kind as not to add to 
the discomfort by tending to ferment. Hence animal 
food is appropriate. Stimulants will often be required, 

15 



174 CONSTIPATION. 

and of these the effervescing ones, as champagne, are 
best. Laxatives are necessary. In some cases com- 
plete emptying of the stomach by the pump and then 
regulating the diet does good, or, as a last resource, 
feeding by the rectum. The vomiting may be con- 
trolled by morphia or ice, and the former will be fre- 
quently required for relief of pain (F. 71). Cundu- 
rango bark has been greatly advocated, of late. 

Constipation. 

Healthy people, as a rule, have an evacuation from 
the bowels once every day, and generally after break- 
fast; yet many in good health have two or three stools 
in the twenty-four hours, while others only have an 
operation every second or third day. Constipation, 
as independent of any acute or chronic disease, may 
be regarded simply as a deviation from the usual rou- 
tine, and as such may be considered, to a certain ex- 
tent, an independent disease. The accumulation of 
fecal matter is frequently due to a sluggish condition 
of the colon, and is attendant on old people, chlorotic 
females, persons having little exercise, and leading 
sedentary lives, or others w T ho think little of and thus 
neglect the calls of nature. As a result of constipa- 
tion there is little appetite, bad digestion, dusky com- 
plexion, and low spirits, with a flabby tongue indented 
at its edges. Sometimes long-continued constipation 
may lead to the formation of an abdominal tumor by 
pressure on the biliary ducts, causing jaundice, or on 
the vena cava, occasioning oedema of the lower ex- 



colic. 175 

tremitics. Exceptional cases have been recorded where 
no motion was effected for ten or twelve weeks. 

Treatment, — A careful regulation of the diet is the 
most important desideratum in treating habitual cos- 
tiveness. For this purpose, the food taken should be 
carefully chosen and slowly masticated. Brown bread 
is serviceable, and ripe fruits may be taken early in 
the morning. Idiosyncrasies of diet should be studied, 
and habitual exercise insisted on. In addition to these 
means nature should be solicited at a certain hour 
daily, the best being immediately after breakfast. All 
pills or strongly purgative medicines should be avoided. 
Of mineral waters, the Hunyadi Janos can be strongly 
recommended. A wineglassful taken every morning 
about an hour before breakfast usually induces a stool 
neither too loose nor copious. Fried richshall and 
Pullna waters are also very useful. The Tamar In- 
dien is serviceable, especially if constipation is asso- 
ciated with piles. A cold shower-bath is advisable in 
the mornings, if there is a healthy reaction afterwards. 
For very old people stimulating the intestinal muscles 
by kneading and rubbing can be recommended. 

Colic. 

Colic is accompanied by severe twisting pain, espe- 
cially about the umbilicus. This pain occurs in par- 
oxysms, is unaccompanied by fever, and is relieved 
by pressure. The bowels are usually found to be con- 
stipated, and bile or mucus may be vomited during the 
attack. 



176 OBSTRUCTION OF THE BOWELS. 

As various diseases of the abdomen have pain as a 
prominent feature, it is useful to remember that the 
pain of peritonitis is persistent, increased by pressure, 
and general over the abdomen ; the pain of the passage 
of a gallstone has a localized area in connection with 
the gall-bladder, and the vomiting is generally severe; 
the pain of a urinary calculus is in the back and tes- 
ticle, with frequent micturition ; the pain of hernia is 
attended with hernial protrusion. 

A peculiar kind of colic attacks painters, or those 
engaged in occupations which bring them in contact 
frequently with white lead. The pain is, however, 
more severe than in ordinary colic, the constipation is 
great, and a peculiar and characteristic blue line is 
observed round the edges of the gums. These symp- 
toms are followed, in advanced cases, by actual paraly- 
sis of the extensors of the wrist and fingers, and wasting 
of the ball of the thumb, constituting what has been 
termed " the drop wrist." 

Treatment — As colic is generally attended with con- 
stipation, and can only be remedied by its removal, 
it is necessary to give aperients, such as are recom- 
mended in the chapter on constipation. An enema 
is also often beneficial, followed by opium, or elec- 
tricity may be tried. For lead colic iodide of potas- 
sium must be given (F. 5). 

Obstruction of the Bowels. 

If obstruction of the bowels is diagnosed, it is the 
first duty of the practitioner, if possible, to elucidate 



OBSTRUCTION OF THE BOWELS. 177 

the cause. Naturally he will investigate and make 
himself certain whether or not it is due to hernia, and 
act accordingly. Failing to discover any hernial 
strangulation at its most common sites, the obstruc- 
tion may be considered dependent on one of three 
great divisions, according to Dr. Haven : 

1st. Intermural, where, as the name implies, the 
mucous and muscular coats of the intestinal walls are 
involved. 

a. Cancerous stricture. 

6. Xon-cancerous stricture. Comprising — 

1. Contractions of cicatrices following ulcera- 

tion. 

2. Contractions of walls of intestines from in- 

flammation, non-cancerous deposit, or in- 

j ur 7- 

c. Intussusception. 

d. Intussusception, associated with polypi. 

2d. Extramural, or those causes acting from with- 
out, or affecting the serous covering : 

a. Bands and adhesions from effusion of lymph. 
6. Twists or displacements. 

c. Diverticula. 

d. External tumors or abscesses; diaphragmatic, 
omental, or obturator hernia. 

3d. Intramural, or obstructions produced by the 
lodgment of foreign substances : 

a. Foreign bodies, hardened faeces ; or, should the 
obstruction be due to cancerous stricture, the sigmoid 
flexure of the colon or rectum is usually affected, and, 



178 OBSTRUCTION OF THE BOWELS. 

in addition to the obstruction, there will also be evi- 
dences of the cancerous cachexia. 

The condition known as intussusception is not un- 
common in children, and is similar to what occurs 
when the finger of a glove is pulled within itself. 
The upper segment of the bowel is generally drawn 
into the lower; thus, the ileum or caecum may be 
protruded into the colon. The occurrence of intus- 
susception is marked by sudden pain, sickness, and 
constipation. 

Should the obstruction be due to bands or twists, 
the lower part of the ileum is the most frequent seat. 

Symptoms. — The principal symptoms are — 

1st. Vomiting, ultimately becoming fecal. 

2d. Pain, varying in severity. 

3d. Increasing tympanitis. 

4th. Hiccough and constipation. 

5th. Inflammatory signs, taking effect on the pulse 
and temperature. 

Vomiting will naturally be most marked and early 
when the obstruction is situated at the upper part of 
the intestine ; and, if unrelieved, death will occur in 
five to ten days, — if in the colon, it may be delayed 
for weeks. Sometimes, by carefully feeling the abdo- 
men, the point of obstruction can be detected by in- 
creased fulness and diminished resonance over this 
particular spot. Besides this, hyperdistension is seen 
above, and diminished distension below, the obstruc- 
tion. This is best seen when the obstruction is low, 
and the gradual filling of the bowel above it may be 



OBSTRUCTION OF THE BOWELS. 179 

observed , with sometimes the coils of intestine mark- 
ing themselves against the abdominal wall. 

Treatment, — At first, when the diagnosis is some- 
what uncertain, castor oil or an enema may be given, 
but neither should be continued if it becomes clear 
that there is a mechanical hindrance to the passage of 
feces. The two principal points then are, — endeavor- 
ing to sustain the strength of the patient by means of 
beef tea and milk, and the relief of pain by opium 
and hot fomentations. Opium sometimes is inadvisa- 
ble, from its tendency to stop peristaltic action of the 
bowels, hence belladonna may be substituted ; or, best 
of all, according to Brinton, a combination of ext. of 
opium, 2 parts, with ext. of belladonna, J part. Ice 
should always be given freely, to allay thirst. 

Thus calling time to our aid by the means indi- 
cated, nature may, in her own way, remove the ob- 
struction, unless, of course, it is due to an unremovable 
cause. 

At an early stage, before there is any possibility of 
gangrene having set in, the patient may be placed on 
his back, with his pelvis raised, and a long stomach- 
pump inserted as far as it wall go. Then warm water 
should be slowly thrown up until the bowels become 
distended. When this occurs the coils of intestine 
should be moved on one another by the hand placed 
on the abdomen. In this way, or by means of air in- 
stead of water, cases have been successfully treated ; 
and besides, we can by this means form an idea of 
the position of the point of obstruction by the amount 
of water capable of being thrown up. 



180 DIARRHOEA. 

Ill some cases it is necessary to nourish by stimu- 
lating enemata. 

Should gastrotomy be resolved on, the advice of a 
surgeon ought to be obtained; keeping in mind, how- 
ever, before resolving on this, that not a few cases are 
spontaneously cured by nature in ways we are not 
well acquainted with. 

DlARRHCEA. 

Diarrhoea is rather a symptom than a disease, yet, 
when the discharge from the bowels is great, special 
treatment may be required for its relief. The charac- 
ter of the stools varies. Thus, they may be fecal, 
although liquid, bilious, watery, mucous, or thin 
serous. Diarrhoea is a prominent symptom in typhoid 
fever, phthisis, various kidney, liver, or nervous affec- 
tions. It may also result from dentition, errors of 
diet, influence of the season, malaria, or mental emo- 
tion. In all cases the stools should be carefully ex- 
amined, as much information can thus be obtained 
with regard to the cause of the diarrhoea. A severe 
kind of diarrhoea, called by some English cholera, is 
accompanied by pains in the abdomen, cramps in the 
legs, and dark bilious evacuations. 

Treatment will depend entirely on the cause. It is 
frequently inadvisable to check it, as it is nature's 
outlet for carrying away offending matter from the 
intestinal canal, or for relieving other organs which 
are diseased. Thus, if due to indigestible food, it is 
better to promote it (for this is the easiest way to stop 



DYSENTERY. 181 

it) by giving tincture of rhubarb or castor oil ; if oc- 
curring in Bright's disease, it should not be interfered 
with, unless it produces great exhaustion. Should no 
direct cause be ascertained, it may be desirable to 
check it in whole or in part. The various prepara- 
tions of opium or other astringents, as sulphuric acid, 
catechu, tannin, etc., are serviceable for this purpose 
(F. 16, 17, 20). 

Boiled milk and lime-water are very useful in the 
diarrhoea of children, preceded by a few grains of 
grav powder if the motions are green and offensive 
(F.'8). 

In severe cases all solid articles of food, vegetables 
and fruit, should be forbidden, and the diet should 
consist of arrowroot, milk, and boiled rice. The local 
application of poultices and hot fomentations helps to 
relieve the pain. 

Dysentery. 

Dysentery consists chiefly in inflammation of the 
mucous membrane of the large intestine. The inflam- 
mation rarely involves the deeper layers, or extends 
past the ileo-csecal valve. It is supposed to commence 
in the solitary glands that lie scattered over the surface 
of this portion of the intestine. These become en- 
larged and prominent, looking somewhat like small- 
pox pustules. They probably form the foci for most 
of the ulcers, which are sometimes narrow and oblong, 
lying across the gut; sometimes very large and irreg- 
ular, with great patches of thickened mucous mem- 
brane. In the severe and fatal cases the whole bowel 

16 



182 DYSENTERY. 

is one tattered mass of disorganization, with fibrous 
shreds and commingled mucus, pus, and blood. 

Dysentery may be either epidemic or sporadic. 
The former is peculiar to tropical climates, and seems 
dependent on a miasma emanating from the soil, at- 
tacking the system generally, and locating itself in the 
intestine ; the latter may occur in all sorts of places, 
in adults as well as children, and is the result of the 
lodgment of masses of fecal matter in the lower bowel, 
which act as foreign bodies, giving rise to inflamma- 
tion ending in dysenteric symptoms. In neither form 
is the disease contagious. 

Symptoms. — Dysentery begins in both its sporadic 
and epidemic variety with diarrhoea, after there have 
been irregular stools or constipation. There are also 
lassitude, want of appetite, and a listless attention to 
ordinary occupations. On the third or fifth day, 
usually in the night, the diarrhoea becomes more 
severe, and attended with shivering and rigors. Pain 
is felt in the abdomen. The desire to go to stoolis 
intense. Little faeces after a time are passed, and 
there is a straining or burning pain at the anus and 
rectum (tenesmus). With the disappearance of the 
faeces there appears bloody mucus, or pure blood, in 
the midst of which are often seen little white clumps, 
or round bits looking like minced raw meat. 

The patient may seek to go to stool from twenty 
to thirty times in a night, and then, as might be ex- 
pected, becomes giddy and faint from loss of blood 
and exhaustion. The disease may last in this acute 
form from six to eight days, with remissions in the 



DYSENTERY. 183 

morning and aggravations at night. As symptoms of 
amendment may be mentioned alternations of mushy 
even formed stools with the characteristic bloody 
mucous ones. In very severe cases the tenesmus in- 
creases; the dejections flow uncontrolled, and are 
largely mixed with blood, collapse sets in, and the 
patient dies of asthenia. 

When the disease becomes chronic, it is very in- 
tractable, with frequent relapses, offensive discharges, 
and. great pain and exhaustion. 

Sporadic dysentery generally terminates favorably. 
The mortality of the epidemie form may reach 40 or 
50 per cent. 

In slight cases convalescence is complete in about 
three weeks, medium severe cases in about seven weeks. 
Severe cases, if they do not terminate fatally on the 
eighth or ninth dav, may last an indefinite length of 
time. 

Treatment. — During an epidemic of dysentery all 
unnecessary crowding should be avoided, and unclean- 
liness prevented. The discharges of the patient should 
be disinfected. Potatoes, salads, unripe fruit, greasy 
food, spices, or pickles, should not be taken ; while 
ripe fruit and stewed apples are advantageous. 

Flannel bandages should be worn round the abdo- 
men, and if the bowels are constipated, a gentle laxa- 
tive of rhubarb may be taken. 

Should an attack of dysentery set in, the patient 
must remain in bed in a room of an equal temperature. 
The diet should consist of milk, strong soup, yolk of 
eggs, the object of the dietary being to form small not 



184 EPIDEMIC CHOLERA. 

bulky stools. Thirst is alleviated by meal gruel, and 
the tenesmus by starch enemas with five to ten drops 
of laudanum in each. Leeches ought to be applied at 
the commencement of the attack to the anus, and after- 
wards what is termed the cathartic or laxative treat- 
ment adopted. Thus, give an emetic of vin. ipecac, 
follow this up by castor oil or tamarinds. On the 
second day they may be omitted, and morphia substi- 
tuted in the evening. On the third day the laxatives 
mentioned may be administered again, and repeated 
on the fifth or seventh day (Heubner). 

Two grains of nitrate of silver to four ounces of 
water are recommended as an enema. Pulv. ipecac, 
in full closes forms the mainstay of English treatment. 

In the very severe forms the object is to prevent 
collapse, hence alcohol, interdicted in the milder varie- 
ties, must be given, and strong soups at frequent inter- 
vals. When the dysenteric attack has reached an 
advanced stage, vegetable astringents, such as tannin, 
rhatany, etc., are necessary. Above all, in chronic 
dysentery, change of air must be tried if practicable. 

Epidemic Cholera. 

The authentic history of cholera dates back only to 
1817, when it made its first appearance in India. 
After a series of destructive epidemics in the East, it 
reached Europe, and was imported from Hamburg to 
Sunderland on October 26th, 1831, from thence spread- 
ing to the great centres of population in this country. 
This epidemic lasted during 1831-32, when there was 



EPIDEMIC CHOLERA. 185 

a lull, the next epidemic being in 1848-49, the third 
during 1853-54, and the last during 1865-66, when 
it was chiefly confined to London. 

Cholera seems, according to the views of most recent 
authorities, to owe its existence to one single ultimate 
cause, a cholera germ, which again is supposed to be 
of a parasitic nature, and develops in the gastrointes- 
tinal tract, in the interior of the follicles, of the small 
lymph and bloodvessels, and of the submucous con- 
nective tissue. If the parasitic origin of cholera is 
granted, it can be understood how in different degrees 
of vitality these germs can be carried by the air in 
viewless numbers, and impregnate the water supply, 
or be drawn directly into the mouth, the different de- 
grees of vitality accounting, to some extent, for the 
choleraic diarrhoea, which, as will be seen, always ac- 
companies the true disease. Experience testifies that 
nurses and hospital physicians exposed to the concen- 
trated miasma from the dejections, or washerwomen 
who wash the linen soiled with cholera dejections, 
rarely escape taking the disease when it is epidemic ; 
while the fact of outdoor physicians attached to hos- 
pitals passing safely from bed to bed, and again out 
into the open air, seems to indicate that cholera is not 
contagious. 

Cholera is more common in hot than in cold weather. 
Males are more apt to be attacked than females. 
Although common in child and adult life, it is pre- 
eminently a disease of between twenty and thirty. 
Excesses of every kind, whether of food, wine, or fruit, 
during the continuance of the epidemic, predispose to 



186 EPIDEMIC CHOLERA. 

it. The average incubatory period is from twelve to 
twenty-four hours, rarely exceeding one week. About 
one-fifth of those attacked survive. 

Symptoms.— Diarrhoea always accompanies the chol- 
era epidemic, coming on suddenly, the stools being 
fluid, painless, yellowish-brown, and in number aver- 
aging from two to four in the twenty-four hours. 
This diarrhoea rarely fails to precede the real attack. 

The attach proper commences during the night. 
The patient awakes chilly and dizzy, and this is rapidly 
followed by a tempestuous diarrhoea, the early stools 
being black and pappy, but as the bile-pigment quickly 
disappears, they exhibit the characteristic rice-water 
appearance. They are passed involuntarily and pain- 
lessly, and in number vary from three to fifteen. After 
the diarrhoea has lasted one or two hoars, vomiting, 
attended with no pain, sets in, at first of the food which 
may have been taken, and latterly assuming a color- 
less whey appearance. Intense thirst and suppression 
of urine are now prominent symptoms. The tongue 
is, as a rule, white. After a few hours distressing 
cramps supervene, especially of the calves and feet — 
rarely of the hands. Sometimes these are entirely 
absent, and the patient sinks without a struggle. 
There is also a considerable fall of temperature, com- 
mencing in the hands and feet, and most marked on 
the face, nose, and tongue. Should there be a tendency 
to recovery, the temperature approaches the normal ; 
if it does not, the features become more pinched, the 
extremities more cold, livid, and collapsed ; the eyes 
dry, the cornea cloudy, and the voice assumes a hoarse 



EPIDEMIC CHOUEKA. 187 

and raveny character, or it may sink into an inaudible 
whisper. This peculiar character has led to its being 
called " vox choleraica." This stage has been termed 
the algid or cold stao-e, and either terminates in death 
or passes into what is called the stage of reaction. 
The earliest sign of improvement, preceding even the 
abatement of the diarrhoea and vomiting, is the return 
of the pulse at the wrist. Heat follows, the blueness 
disappears, the temperature becomes normal, and con- 
valescence may be regarded as perfect in from ten to 
fourteen days. Sometimes the improvement is only 
transient, being followed by uraemia, or inflammation 
of the kidneys or intestines. During the attack proper 
the patient may die in from six to eight hours ; even 
in bad cases the usual time is, however, twenty-four 
hours. 

Morbid Anatomy. — Cholera has no distinctive le- 
sions ; the cadaveric rigidity is, however, marked. In 
the digestive tract the isolated and agminated glands 
are swollen and prominent, more especially the latter. 
At the ileo-esecal valve, a whitish-gray fluid, with fine 
granules and cell-nuclei, exudes if the follicles are 
pierced. These changes are seen during the first forty- 
eight hours. Afterwards the swelling diminishes, and 
the glands are shrivelled up, collapsed, and of a yel- 
lowish or slaty-gray color. The brain, heart, lungs, 
and liver are usually found healthy, while the kidneys 
are larger than usual, and congested. 

Treatment is of two kinds — prophylactic and thera- 
peutic. During a cholera epidemic all unnecessary 
meetings, fairs, and pilgrimages should be abandoned. 



188 EPIDEMIC CHOLERA. 

Wells ought to be inspected, defective sanitary arrange- 
ments remedied, dirt of every kind cleared away, the 
sale of unripe fruits and vegetables prevented, soup- 
kitchens established, and the stamina of the poor built 
up. The prodromic diarrhoea should, if cholera ap- 
pears, be checked as early and speedily as possible " by 
the sole and only agent," which, Lebert says, " has a 
real protective character " — viz., opium. 

R. Acid, sulph. dil., .... giiss. 

Tinct. opii, ...... ^iss. 

Sp. chloroform., ..... ^ij. 

Aq. menth. pip., . . . .-'§▼}.. M. 

A tablespoonful after every motion. If the diarrhoea 
is more obstinate, a powder every four hours of 

Pulv. opii, . . . 

Tannin, 

Bismuth subnit., .... 
Sacch. alb., ..... 

Also inject every twenty-four hours, 

Argent, nit., .... 
Tinct. opii, .... 

In starch water, .... 

If these remedies fail we must now fall back on, or, 
as some authorities say, commence with a teaspoon- 
ful of castor oil or tincture of rhubarb. 

If the diarrhoea resists our efforts, and true cholera 
with violent discharges begins, astringents are of no 
avail, and in fact do harm. Ice should be placed 
on the tongue every few minutes, and carbonic acid 



gr. 


ss. 


gr. 


"J- 


gr. 


V1 J 


gr. 


"J- 


gr. 


y. 


T^XV. 


Z"i- 



INTESTINAL WORMS. 189 

water drank. Morphia may be injected subcutane- 
ouslv to allay the pain and cramps, and sinapisms ap- 
plied over the abdomen, while the legs are rubbed 
with some stimulating liniment. Should the tempera- 
ture begin to fall, enveloping the patient in a blanket 
wrung out of hot water and sprinkled with turpentine, 
together with the internal administration of the same 
drug, was, in my experience, successful during the 
last London epidemic. In rapidly sinking cases brandy 
or champagne may be given (F. 72). 

When reaction sets in, a large spoonful of good 
beef tea may be taken every three hours, and later on 
tea or coffee with milk several times a day. From 
this we may pass to a more increased and solid diet. 

" The best treatment of cholera," says Lebert, 
" therefore, in the state of existing knowledge, is a 
carefully regulated hygienic and a correctly interpreted 
symptomatic treatment, with avoidance of all pertur- 
batory efforts, in the last degree inutile if not even 
injurious/' 

Intestinal Worms. 

Of the different intestinal worms which inhabit the 
human body there are two great varieties, — the hollow 
worms and the solid worms. In the first class we 
find three species of tenia, the most common being 
the Tcenia solium. Its length varies from two to ten 
yards or more, and its habitat is the small intestine. 
It consists essentially of a head and segments. The 
head is about as large as a small pin's head flattened, 



190 INTESTINAL WORMS. 

with a double circle of hooks, around which are four 
suckers or mouths by which it attaches itself to the 
intestine. The segments, joints, or proglottides, are 
rectangular, and possess male and female organs 
opening into a common aperture retaining the ova, 
which, when ripe, contain a six-hooked embryo. The 
joints are at first more broad than long, but as they 
diminish in distance from the head they become smaller 
and smaller, and the length exceeds the breadth. 
The Cysticercus cellulosce, a parasite chiefly resident in 
pigs, seems to be the parent of the Taenia solium in 
man, and from uncooked or improperly cooked pork 
the tapeworm is developed in the human body. 

Symptoms. — The only phenomenon which seems to 
indicate the presence of the parasite is the appearance 
of segments in the feces. Sometimes the victims of 
tenia also complain of pain in the belly, unsatisfied 
appetite, thirst, great depression of spirits, with itch- 
ing of the anus and nose. 

Varieties. — Tcenia mediocanellata resembles very 
much the former variety, but it has only a sucking 
apparatus in the head, no hooks. It appears to result 
from the further development of a cysticercus infecting 
cattle, and owes its introduction into the system to 
the eating of improperly cooked beef. 

The Bothriocephalus latus, peculiar to Switzerland, 
Russia, and Poland, is the largest of all the tapeworms, 
sometimes attaining a length of twenty-five feet and 
upwards, each foot containing a hundred and fifty 
segments and joints, and each joint having its own 
male and female organs. The head is club-shaped, 



.ROUND-WORMS. 191 

with a longitudinal slit by which it attaches itself, 
but no suckers. 

Treatment. — When the presence of the worm has 
been discovered, the best way to expel it is to tell the 
patient to take no food for eight hours, then to ad- 
minister in the evening 30 TT£. of the ext. of male 
fern in a draught of peppermint water. Follow this 
up in the morning with a dose of castor oil, and about 
midday by a large plate of mashed potatoes. The 
head and segments will probably be thus forced away ; 
if not, let the same treatment be adopted on a subse-. 
quent occasion (F. 29). 

The bark of the pomegranate root, or kousso, or oil 
of turpentine, are well-known anthelmintics, but in- 
ferior to the male fern. 



Round-worms 

Possess a distinct integument and an alimentary 
canal, with a mouth at one end and an anus at the 
other. The sexes are always separate. In the male 
the genital pore is near the anus, in the female about 
the middle of the belly. 

1st. Ascaris lumbricoides, the common round-worm, 
resembles much the common earthworm. The female 
is nearly twice as large as the male. Its habitat is the 
small intestine, generally of badly fed children, but 
from this it may creep upwards to the stomach or to 
the colon, and it has also been found in the nose, 
hepatic or pancreatic ducts. Authentic records indi- 
cate that a large number of lumbricoides may be in 



192 KOUND-WORMS. 

the body at the same time. As a rule, however, they 
rarely exceed five or six. They may penetrate the 
intestinal wall to the peritoneum, causing an abscess 
near the umbilicus. The symptoms are obscure and 
various. Generally speaking, there is thirst, dis- 
turbed sleep, fever, and depraved appetite, with itch- 
ing of the nose and anus. 

Treatment, — The best remedy is santonin given in 
one to three grains twice daily to a child, or double that 
quantity to an adult. Turpentine may also be given 
if preferred (F. 30). 

2d. The common threadworm ( Oxyuris vermicularis) 
is small, white, and threadlike, the female being about 
the third of an inch long, the male about half that 
length. They exist in the colon or rectum, generally 
in great numbers at a time, and infest children who 
are badly fed or in indifferent health. 

The chief symptom is itching at the anus or at the 
nose, with bad breath and generally indifferent health. 
The diagnosis can easily be confirmed by observing 
them in the fseces. 

Treatment — Enemata of cold water, of infusion of 
quassia, of tea, or liq. calcis, repeated daily, are suffi- 
cient to kill the oxyures, with occasional doses of 
hydrarg. c. cret. For adults, perchloride of iron, half 
an ounce to a pint of water, is recommended. 

The whipworm (Triehocephalus dispar) and the 
Sclerostoma duodenale are rarely seen in this country, 
although the former is sometimes observed in people 
who have died of typhus or enteric fever. 



trichina spiralis — trichinosis. 193 

Trichina Spiralis — Trichinosis. 

The Trichina spiralis is met with in the muscular 

tissue in the form of a minute worm, which lies coiled 
up in the interior of an oval cyst, giving to the naked 
eve an appearance like minute white grains. These 
trichinae are discovered chiefly in the flesh of pigs, 
and it is from the use of trichinous pork that man 
has become affected. The trichinae cysts are dissolved 
by the gastric juice, and the parasites set free. Sex- 
ual maturity is developed, the ova and the living em- 
brvos at once commence active migration, findings 
their way into the small vessels or lymphatics of the 
bowels, and from thence they are conveyed over the 
body. In this way they penetrate the intestine, irri- 
tating it in their passage, getting to the intermuscular 
tissue of the trunk and limbs, and thence penetrating 
the muscular tissue and destroying it. 

Symptoms. — These first consist of intestinal disturb- 
ance, not unlike that of typhoid fever, with coated 
tongue, diarrhoea, and great prostration. Secondly, 
muscular inflammation, pain, and tenderness, not un- 
like rheumatism, with stiffness and rigidity over the 
voluntary muscles. Then dropsy commences in the 
face, goes to extremities, and even involves serous 
cavities. 

The duration and severity of trichinosis vary ac- 
cording to the number of the animals; in some cases 
recovery taking place in a month, in others in three 
or four. In some outbreaks the mortality is small, 



194 PERITONITIS. 

in others as much as twenty-five per cent., and it may 
result from peritonitis, pneumonia, or debility. 

Treatment. — We can only treat symptoms, as we 
know of no remedy specially adapted to kill the para- 
sites. Prophylactically, avoid raw or undone pork 
or German sausages. 

Peritonitis. 

The peritoneum or serous membrane lining the ab- 
dominal and pelvic cavities, and investing the viscera, 
may suffer from acute or chronic inflammation. The 
inflammation is precisely similar to what occurs in all 
serous membranes, viz., capillary congestion, redness, 
more or less loss of polish, exudation resulting in a 
thin grayish lamina, which ultimately becomes thicker, 
and ribbed or villous according to position. The sur- 
face of the intestine is injected, the intestines are slightly 
glued together with soft yellow-gray lymph shifting 
from one fold of the peritoneum to another. In the 
pelvic cavity turbid fluid floats, with flakes of lymph. 
The fluid effused is chiefly observed in chronic cases, 
and tends naturally to gravitate to the lower and 
more dependent parts, e.g., into the pelvis and lum- 
bar regions, where it may escape observation ; or, if 
excessive, distend the abdominal walls. This fluid 
may be clear or bloody, or become rapidly or slowly 
purulent. 

Peritonitis, even though of local origin, tends to 
spread until the whole of the peritoneal surface is 
involved; and convalesce nee, should it occur, is at- 
tended with absorption of the fluid, organization of 



PERITONITIS. 195 

the false membrane, and thickening of the peritoneal 
surface, with adhesions of adjacent organs. Should 
the fluid be purulent, it may form an external abscess, 
or escape into the intestines. 

Causation. — Peritonitis is occasioned by injuries, 
hernia, perforations, and extension of disease from 
neighboring parts ; it is also the result of various blood 
diseases, as puerperal fever, tubercle, Bright's disease ; 
sometimes it is acute aud idiopathic, and due to expo- 
sure or wet. 

Symptoms. — In the acute form, however occasioned, 
the symptoms are marked by fever, and w T ith the 
fever there is pain in the abdomen, increased on pres- 
sure or by the slightest movement. The patient lies 
in bed with the legs drawn up. The face is anxious 
and pinched, and the abdomen is tympanitic, tense, 
and hot. Vomiting is often present, and when so 
naturally aggravates the pain. The urine is scanty 
and high-colored, the pulse is rapid, hard, and wiry, 
the tongue parched, and the respiration quick and 
shallow. Should the disease take a favorable turn, 
the gravity of the symptoms abates, the fever dimin- 
ishes, and the pulse becomes normal. If, on the other 
hand, a fatal issue is to result, the abdomen becomes 
distended, the pulse thready, the extremities cold, and 
collapse sets in, with or without loss of consciousness. 
Death may occur as earlv as the second or third dav, 
or it may be delayed for a week. 

Treatment. — This consists in enforcing absolute rest, 
and maintaining the position which is instinctively 
assumed, at the same time guarding the patient from 



196 CHRONIC PERITONITIS. 

the unnecessary weight of the bedclothes by means of 
a cradle. Should the disease be idiopathic and seen 
early, leeches should be applied to the abdomen, and 
the bleeding encouraged by hot fomentations. Opium 
should also be given by the mouth or by rectum, or 
morphia injected subcutaneously in such quantities as 
will insure relief from the pain. 

The strength must also be sustained by liquid 
nourishment, beef tea, eggs, and milk. In very acute 
cases an ice-bag over the abdomen, with two or three 
layers of flannel between, is very useful. If perfora- 
tion is suspected, abstinence from food or stimulants, 
and nourishment by enemata are indicated. Ice to 
suck is very grateful, and mitigates vomiting. Treat- 
ment by blisters has been advocated, but the inflam- 
mation is too general for such treatment. 

Chronic Peritonitis 

Sometimes follows the acute affection; generally, 
however, it is an independent affection, associated 
with the strumous diathesis. Numerous miliary gran- 
ules lie within or immediately beneath the membrane, 
especially in the folds of the peritoneum which com- 
pose the omentum. When there are symptoms of 
chronic peritonitis, with evidences of a strumous con- 
stitution and no history of a previous acute attack, 
Louis seems to think that these granules will always 
be found. 

Symptoms. — These are obscure, and steal on the 
patient in a very insidious manner. Usually pricking 



TYPHLITIS AND PERITYPHLITIS. 197 

pain is experienced in the abdomen, and the belly gets 
full and tense. The pain is increased on pressure. 
There are also loss of appetite, nausea, fever, and pro- 
gressive emaciation, with diarrhoea. After a time the 
effusion of fluid takes place, the abdomen enlarges, 
and fluctuation is felt. With this tubercular peri- 
tonitis there is often combined disease of the mesen- 
teric glands, phthisis, etc. The fluid does not gravi- 
tate so freely on account of adhesions, and this fact, 
with the thickening of the peritoneum, serves to dis- 
tinguish this affection from ascites. Another useful 
sign is friction-sound, heard by the ear or stethoscope, 
and produced by respiration or movement of the ab- 
dominal wall. 

Treatment. — Mild nutritious diet — milk, beef tea, 
etc.; iodine ointment applied externally; while in- 
ternally syr. iod. ferri and cod-liver oil must be ad- 
ministered. These cases are very unpromising, and 
unless chronic peritonitis is the consequence of the 
acute attack, not much benefit will ensue from any 
form of treatment. Opium fomentations, or even 
blistering, may be used if the severity of the symptoms 
indicates them. 

Typhlitis and Perityphlitis. 

In the right iliac fossa lies the caecum and its 
appendix, only anteriorly and laterally covered by 
peritoneum. Inflammation not unfrequently attacks 
this particular part of the intestine, and if the inflam- 
mation affects the mucous surface and the coats of the 

17 



198 TYPHLITIS AND PERITYPHLITIS. 

caecum, it is termed typhlitis (rocpXoq, blind ; terminal 
itis) ; while if the areolar tissue connecting the caecum 
to the psoas and iliacus muscles is also involved, the 
term perityphlitis is employed. 

Various causes may originate the inflammation. 
Thus concretions may accumulate in the vermiform 
appendix, or bits of bone, pins, bristles, etc., may 
stick there, or any of the intestinal ulcers may perfo- 
rate the bowel at the place mentioned. Should the 
perforation occur where the bowel is free from peri- 
toneal covering, fecal matter escapes directly into the 
surrounding tissues, leading to inflammation and ab- 
scess, which may take a varied course; at one time 
opening into the rectum, or forming a swelling in the 
groin, or passing downwards along the psoas and ilia- 
cus muscles to point at the upper part of the thigh. 
In the majority of cases it presents itself in the iliac 
region in the position which the caecum usually oc- 
cupies, from whence it may be discharged either by 
one of the w T ays previously alluded to, or it may again 
enter the caecum by its original orifice ; or a series of 
sinuses may be formed, which never entirely close. 

Should perforation take place directly into the 
peritoneal cavity, fatal peritonitis will of course result. 

Symptoms and Progress. — The early symptoms are 
pain and tenderness in the iliac region, with rigors 
and fever. The patient lies on the right side, with 
legs drawn up. If the abscess forms and extends 
downwards, the symptoms are obscure ; if it tends to 
point anteriorly, the fulness and hardness become more 
pronounced, and the contents may be discharged into 



DISEASES OF THE LIVER. 199 

the bowel, or externally by an artificial anus. Should 
the discharge be into the peritoneum, the local symp- 
toms of pain and tenderness will not be confined to 
one particular spot, but be general over the abdomen, 
occasioning great suffering and death in a few hours. 

The duration of typhlitis is uncertain, sometimes 
ending in speedy recovery, or in death from a linger- 
ing and obscure illness. 

Treatment, — Locally, leech and apply hot fomenta- 
tions or poultices. Internally, avoid giving drastic 
purgatives. Keep the bowels quiet with opium in 
any of its forms. Give only liquid food, and allow 
wine or brandy should exhaustion or suppuration 
appear. 

Should the bowels not open naturally, castor oil 
may be taken if enemata fail. 



DISEASES OF THE LIVER. 

The ordinary extent of hepatic dulness in an adult 
of average size is 4 inches in the right mammary line, 
i. e., a line descending perpendicularly from the right 
nipple ; 4 J or 5 inches in the right axillary line, 4 inches 
in the right dorsal line, i. e., from lines drawn respec- 
tively from the centre of the axilla, and from the 
lower angle of the scapula; 3 or 4 inches in the 
median line anteriorly,/. e., corresponding to the base 
of the ensiform cartilage. 

Its position is somewhat arched. Commencing pos- 



200 DISEASES OF THE LIVER. 

teriorly about the tenth or twelfth dorsal vertebra, it 
ascends gradually towards the axilla and the nipple, 
and then again descends slightly towards the median 
line in front. 

The liver may become enlarged from the normal 
dimensions given, and as this enlargement is a char- 
acter common to many diseases of the organ, it has 
been happily suggested by Dr. Murchison to divide 
these, for the purposes of diagnosis, into painless and 
painful enlargements. Painless enlargements are 
further characterized by an absence of jaundice and 
by a very chronic course ; but in the painful enlarge- 
ments jaundice is a very common symptom, and the 
progress is more rapid. 

Among painless enlargements we have the so-called 
amyloid liver, the fatty liver, hydatid tumor of the 
liver, and simple hypertrophy. 

Among painful enlargements we have congestion, 
catarrh of the bile-ducts, obstruction of the common 
duct, and retention of bile, cancer, pysemic and trop- 
ical abscesses. 

Painless Enlargements of Liter. 

Waxy, Lardaceous, or Amyloid Liver. — The liver 
may attain, under this disease, a great and uniform 
size, with a rounded, well-defined lower margin. The 
growth is slow and imperceptible, extending over many 
years, with constitutional symptoms of anaemia, and 
frequently with evidences of a similar disease in kid- 
neys, stomach, and spleen, the latter being often en- 




7 /E N ! A E C H I -N C C C U S , 

FROM HYDATID CYST OF LIVER. 



PAINLESS ENLARGEMENTS OF LIVER. 201 

larged as well as the liver. The conditions favoring 
this degeneration are, as in the kidney, constitutional 
syphilis or other exhausting diseases. From the nature 
of the disease it may be expected that it can hardly 
result in recovery, although its progress may be some- 
what arrested. 

Fatty Liver. — The enlargement is considerable, but 
not so great as in the previous form. To the feel, if 
the abdominal walls are thin, it seems soft and doughy, 
and can easily be pushed aside by the finger without 
causing any pain. Many and opposite conditions of 
the system may give rise to fatty liver. Among these 
may be specially mentioned alcoholism, phthisis, and 
general obesity, so that it may rather be considered as 
an adjunct to other constitutional states than a disease 
per se. Dr. Addison considered a greasy velvety con- 
dition of the skin characteristic of fatty liver. On 
post-mortem examination the liver is found to be pale, 
staining the knife with grease on cutting into it. The 
disease is most marked round the lobules, the cells 
being enlarged and containing fatty globules. 

Hydatid tumor depends on the development in the 
liver of the taenia echinococcus, which inhabits the in- 
testines of the dog. The taenia is supposed to be voided 
with the feces of the animal, and to enter the human 
system by means of food and drink, finding its way 
to the liver or other organs in an unexplained manner. 
Hydatid tumors of the liver, unlike those previously 
considered, are not uniform in their direction, but 
usually follow one direction in particular, either up- 
wards, downwards, or laterally; hence the tumor 



202 DISEASES OF THE LIVER. 

formed may burst into the peritoneum, stomach, intes- 
tine, or lung. Sometimes it may suppurate, or it may 
dry up. The commencement is usually insidious, and 
the tumor may attain a great size without the patient 
being aware of its existence. Occasionally, if near to 
the surface, there is a sign elicited by percussion, known 
as " hydatid vibration," characterized by a peculiar 
trembling sensation being imparted to the three fingers 
of the left hand when they are laid flat on the tumor, 
and the back of the left middle finger is struck ab- 
ruptly with the point of the middle finger of the right 
hand. 

In simple hypertrophy the enlargement is not great, 
and is not attended with any prominent symptoms. 
It has been chiefly observed in some cases of diabetes 
and leucocythsemia. 

Treatment — The treatment of these painless affec- 
tions of the liver is unsatisfactory. In waxy liver 
the diet ought to be nutritious, with a moderate allow- 
ance of stimulants. The tincture of iodine may be 
given, in doses of fifteen minims diluted, thrice daily. 
Complications, such as diarrhoea, vomiting, etc., must 
be treated as they arise. In fatty liver, if dependent 
on indolent habits, an anti-saccharine or Banting diet- 
ary with exercise must be enforced. If due to alcohol, 
withdraw the stimulants. In both cases, alkalies with 
taraxacum are useful, and if circumstances permit, the 
waters of Carlsbad, Marienbad, or Homburg can be 
strongly recommended. Iodide of potassium and 
common salt were at one time considered serviceable 
in hydatids of the liver, but subsequent experience 



PAINFUL ENLARGEMENTS OF LIVER. 203 

has not confirmed the hopes held forth, and it is now 
deemed advisable, if the tumor is increasing, to punc- 
ture and remove the liquid contents of the cyst by a 
fine trocar and can u la. This being done, both the 
parent hydatids and offspring die. Out of forty-six 
cases reported by Dr. Murchison, thirty-five appear to 
have been perfectly successful. It is necessary only 
to withdraw a portion of the fluid to cause the death 
of the hydatid. 

Painful Enlargements of Liver. 

Congestion. — The phrase congestion of the liver is 
too often used vaguely and applied to cases of indi- 
gestion, when, probably, there is little amiss with the 
organ. In true congestion there is uniform though 
not very great enlargement of the organ — probably 
to the extent of an inch — which disappears after a 
time, the surface projecting below the ribs being per- 
fectly smooth, tender on pressure, and accompanied by 
an uneasy feeling rather than acute pain, radiating 
from the liver up to the right shoulder. This feeling 
is increased to actual pain sometimes after meals, or 
when the patient lies on the left side. Jaundice, rarely 
intense, is present after two or three days, with nausea, 
loss of appetite, headache, scanty high-colored urine, 
and other symptoms of indigestion. There may also 
be in acute cases evidences of obstructed circulation in 
splenic enlargement or ascites. 

Hepatic Congestion may be due to mechanical 
causes, e. g., consequent on disease of the mitral or 



204 DISEASES OF THE LIVER. 

tricuspid valve, or it may be dependent on errors of 
diet, excessive tippling, sedentary life, malarious or 
other poisons, or upon suppression of habitual dis- 
charges — the catamenia or bleeding from piles — or 
habitual constipation. 

Treatment will vary with the cause, but in all cases 
attended with any severity hot poultices should be ap- 
plied, with, in some instances, the application of leeches 
to the anus. The diet should be unirritating and non- 
alcoholic. Purgatives of sulphate of soda or magnesia, 
aided by blue pill or podophyllin, should be given at 
first, followed by the mineral acids, with taraxacum 
and gentian. When wine requires to be taken, dry 
sherry and claret are to be preferred. 

Catarrh of the Bile-Ducts is associated with 
the same clinical characters as those of congestion, yet 
with more marked tenderness over the gall-bladder, 
which sometimes can be felt as a pyriform tumor, 
while obstruction of the common duct has the further 
addition of jaundice. 

Cancer of Liver, in fully three-fourths of the 
cases, is secondary to cancer in other organs, as the 
stomach, uterus, or female breast. It runs a rapid 
course, being rarely prolonged beyond twelve months. 
It is attended with great pain and nodulated enlarge- 
ment, generally with jaundice and ascites, and with 
other evidences of malignant disease. 

Treatment can only be palliative. 

Pyemic and Tropical Abscesses differ in this, 
that the former are many in number and small, while 
the latter is usually single, and may attain a large size. 



PAINFUL ENLARGEMENTS OF LIVER. 205 

The former are simply the evidence of the constitu- 
tional state termed pyaemia ; while the latter, though 
rare in this country, may follow the acute hepatic in- 
flammation of tropical climates. This inflammation 
has the symptoms detailed in congestion in an aggra- 
vated form, with the addition of high fever, and fre- 
quently troublesome hiccough. Should the inflamma- 
tion end in the formation of an abscess, this will be sig- 
nalized by chills and hectic fever, and by fluctuation 
more or less distinct, according to the distance of the 
abscess from the surface. The abscess, which is not 
generally very rapid in its progress, may burst into 
the peritoneum, giving rise to fatal peritonitis, or open 
into the biliary ducts and be discharged by the duo- 
denum. More frequently, however, when the matter 
gets near the surface of the gland, adhesive inflamma- 
tion is set up in the portion of the peritoneum imme- 
diately above it, and lymph is poured out which glues 
the organ to adjacent parts — to the abdominal parietes, 
the diaphragm, stomach, or some part of the intestine, 
the pus being then discharged externally, or into the 
lung, pleura, or stomach. (Tanner.) 

Tropical Abscess is often associated with, and 
some consider it the result of, dysentery. 

Treatment is similar to that mentioned, under con- 
gestion, in addition to the employment of chloride of 
ammonium and ipecacuanha in large doses. After 
suppuration has been established, the diet must be 
generous, and wine or brandy allowed. Operative in- 
terference seems advisable when there is a visible fluc- 
tuating tumor, when a distinct tumor projects from 

18 



206 DISEASES OF THE LIVER* 

the normal contour of the liver even should there be 
no fluctuation, and when constitutional symptoms in- 
dicate its presence though there should be no local 
signs. It is inadvisable when, from jaundice or other 
symptoms, there is reason to fear the existence of nu- 
merous abscesses. The operation should be performed 
with antiseptic precautions, or, if the abscess is large, 
by means of Bowditch's syringe or Dieulafoy's as- 
pirator. 

Contractions of the Liver. 

The area of hepatic dulness may be diminished in- 
stead of increased, and under the head of hepatic con- 
traction we have — 1, simple atrophy ; 2, acute atrophy ; 
3, cirrhosis. In simple atrophy there is simply a dimi- 
nution of the size and no alteration in the structure of 
the organ. The liver may be reduced to one-half its 
normal weight and bulk. The circumstances under 
which it occurs are two, viz., old age and inanition, 
the latter being dependent on either an insufficient 
supply of food from actual want, or on a defective as- 
similation arising from other diseases, as cancer of the 
stomach. 

In acute atrophy, not merely is the liver rapidly 
diminished in size, but the structure of the gland is 
altered. The secreting cells are broken up into granu- 
lar matter and oil-globules, and the whole organ is 
found after death to be soft and yellow. The disease 
is rare and caused by unknown conditions, though it 
is most common in pregnant females. It results almost 



CONTRACTIONS OF THE LIVER. 207 

invariably in death by coma, preceded by gastric ca- 
tarrh, bilious vomiting, jaundice, and cerebral symp- 
toms of a typhoid character, with low muttering de- 
lirium and albuminous urine. 

Treatment is unsatisfactory, though temporary im- 
provement sometimes follows smart purgation by sul- 
phate and carbonate of magnesia. 

Cirrhosis, the so-called gin-drinker's or hobnailed 
liver, derives its name from xippoq, yellow, the color 
being due to the large amount of yellow pigment 
found in the secretins; cells. The liver becomes re- 
duced in size in consequence of destruction of its se- 
creting tissue, this destruction again being due to hy- 
pertrophy of the connective tissue. The organ is thus 
dense and preternaturally hard, its outer surface being 
granular and nodulated, and on section it presents 
firm fibrous bands, including the remains of vessels 
and bile-ducts and surrounding islets of yellow secret- 
ing tissue. 

The disease is chronic, usually extending over several 
years, with an insidious commencement, and probably 
increase of size, but latterly by diminished bulk of the 
liver. In its early stages it is attended with symp- 
toms of what may be termed alcoholic dyspepsia, sick- 
ness and retching in the morning, loathing for solid 
food, and a strong desire for stimulants, with slight 
pain or tenderness over the hepatic region. In late 
stages, when the portal circulation has become ob- 
structed, its hobnailed character may be felt exter- 
nally — ascites appears and gradually increases, the 



208 DISEASES OF THE LIVER. 

spleen enlarges, and haemorrhoids and hemorrhages 
from the stomach and bowels occasionally occur. The 
disease is marked by progressive emaciation and de- 
bility, by a persistent sallow complexion, though actual 
jaundice is rare, by increasing dyspeptic derangements, 
and results fatally, sometimes by exhaustion, attended 
with coma or oedema and inflammation of the lungs. 
It is chiefly met with in adults between 35 and 60, in 
males more than females, and is almost invariably 
connected with a previous history of undiluted spirit- 
drinking on an empty stomach. 

Treatment — In the early stages the essential thing 
is to stop drinking habits. Spirits should be for- 
bidden, although a little claret or hock may be allowed. 
The diet should consist of milk, eggs, plainly cooked 
white fish, game, and meat, with an avoidance of all 
hot spiced or greasy food. Regular exercise should 
be enjoined, and the action of the bowels facilitated 
by occasional saline or mineral water aperients, and 
the use of nitro-muriatic acid. In the second stage, 
though curative treatment is impossible, yet the same 
dietary must be enjoined. Purgatives and diuretics 
should be given for the ascites, and these failing^ 
tapping must be had recourse to (F. 27, 35). 

Jaundice. 

The term jaundice is derived from the French 
jaune, yellow. Icterus, the Greek word for the golden 
thrush, another synonym, originated in the ancient 
idea that a sight of this bird by a jaundiced person 



JAUNDICE, 209 

was death to the bird but recovery to the patient. 
The affection has also been termed u regius morbus/' 
from the royal and pleasant regimen prescribed for 
those who had it. Jaundice may be considered as a 
yellowness of the skin and conjunctivae, and the tissues 
and secretions generally, from impregnation with bile 
pigment. It is not, as this and preceding remarks 
indicate, a disease _per se, but a symptom accompany- 
ing many complaints, and its existence lias given rise 
to much controversy and many conflicting statements. 
All cases of jaundice may be referred to two great 
causes, 1st, when it results from obstruction to the 
common bile-duct; 2d, when it is independent of any 
obstruction. With regard to the first and most com- 
mon origin there is not much dispute, as it is obviously 
then dependent on the bile which has been secreted 
being reabsorbed into the system. On the second 
point Frerichs's explanation, adopted by Dr. Murchi- 
son, seems to be the most feasible. It proceeds on the 
supposition that even in health bile to a greater or less 
extent is reabsorbed into the system (in addition to 
what also passes away by the faeces), and is at once 
transformed so that neither bile-acids nor bile-pig- 
ment can be discovered in the blood or in the urine, 
and consequently there is no jaundice. But in certain 
morbid states this transformation does not occur, and 
hence it circulates in the blood and stains the skin and 
other tissues, and jaundice is produced. These mor- 
bid states are the results of certain poisons, yellow 
fever, relapsing fever, snake-bites, nervous influences, 
fear, rage, deficient supply of oxygen, or an excessive 



210 JAUNDICE. 

secretion of bile with great constipation. The ob- 
structive causes, on the contrary, are from within, 
as gallstones,* foreign bodies from the intestines ; or 
from without by pressure, as cancer of the liver or 
pancreas, loaded intestine, pregnant uterus, ovarian 
tumors, etc. 

Symptoms. — The skin and conjunctivae are of a 
yellow color, the urine stains linen yellow, while on 
a few drops of nitric acid being added to it on a white 
plate, a play of colors, green, violet, pink, and yellow, 
is developed ; the faeces are whitish or of a light clay 
appearance. The skin is often itchy, the temper irri- 
table, the taste bitter, with a sleepy, drowsy sensation 
at all times. The function of digestion is uninter- 
fered with, except in regard to fatty articles. 

Cerebral derangements may supervene if jaundice 
continues long, with stupor and delirium and a ten- 
dency to hemorrhages. If the obstruction is due to 
an impacted gallstone, the suffering may be intense, 
and the pain is known as biliary colic. Vomiting and 
hiccough frequently accompany. Fatal exhaustion 
may ensue should the concretion not pass through 
the duct. 

Treatment. — This must vary with the cause, but if 
due to obstruction, as from gallstones, hot poultices 
should be applied, or a few leeches if the attack has 
been long and severe, with the subcutaneous injection 

* Gallstones consist of thickened bile, which in some in- 
stances has formed round a nucleus of solid biliary matter. 
They may exist in great numbers. 



DISEASES OF THE PANCREAS AND SPLEEN. 211 

of morphia. Immediate relief is sometimes afforded 
by large draughts of hot water with one to two 
drachms of bicarbonate of soda to the pint. Chloro- 
form is sometimes necessary. To prevent a refor- 
mation of gallstones the waters of Vichy and Carls- 
bad are useful. 

" In other cases of jaundice," says Dr. Tanner, " as 
we shall be merely working in the dark, it will be 
better to rest contented with resorting to gentle saline 
purgatives, diaphoretics, baths, rest, and regulated 
diet." 



DISEASES OF THE PAXCREAS. 

Clinically we know little of the diseases of the 
pancreas, as the organ is rarely affected primarily. 
Lying deep in the epigastric region, behind the 
stomach, and in front of the aorta, it must be remem- 
bered that if a tumor exists in connection with it, it 
will be discovered in this region, and that pain will 
be referred either to the front or to the back at the 
junction of the lumbar and dorsal vertebrae. The 
principal diseases to which the pancreas appears liable 
are morbid growths (chiefly scirrhus), calculi (of phos- 
phate of lime) of varying size, obstructing the chief 
duct, and leading to enlargement of the organ and the 
formation of cysts; catarrhal inflammation of the 
same duct, probably in the same connection ; and in- 
flammation of the chief duct. 



212 DISEASES OF THE SPLEEN. 

The symptoms of any of these affections daring life 
are obscure, and attended with debility and malnutri- 
tion. As one of the principal functions of the pan- 
creas is to assist the digestion of fatty compounds in 
the food, the presence -of fat in the stools has been de- 
tected in diseases of this organ. 

Treatment — All special treatment of affections so 
difficult to diagnose during life seems out of the 
question. 



DISEASES OF THE SPLEEN. 

The spleen, situated in the left hypochondrium, 
weighs about six ounces; its length being six inches, 
and its breadth rather more than three inches. Its 
external surface is convex; its internal border, which 
is concave, is in relation with the cardiac end of the 
stomach, and has a vertical fissure — the hilus — at 
which apertures are found for the entrance and exit 
of vessels and nerves. It has no excretory duct, and 
its exact purpose in the system is as yet undetermined. 

Composed essentially of an elastic fibrous frame- 
work (trabecular tissue), of Malpighian corpuscles, and 
of spleen pulp, it may become distended with blood 
from slight causes, especially from those which inter- 
fere with the action of the skin, the liver, or the kid- 
neys. These causes continuing, its elastic power may 
be lost, and it thus becomes unable to send the accu- 
mulated blood onward. It may thus suffer from con- 



DISEASES OF THE SPLEEN, 213 

gestion leading to inflammation, abscess, and gangrene; 
or it may be the seat of malignant disease, of fibrinous 
deposits, or serous and hydatid cysts may form with- 
in it. 

Splenic diseases of any of the above-mentioned 
forms may occur at any age, especially if the indi- 
vidual is resident in tropical climates. The most 
common of these is enlargement, commonly known as 
ague cake. The history of the case, as associated with 
intermittent fever or ague, or residence in the tropics 
even without having contracted fever, and the marked 
increase in the size of the organ, form clues to diag- 
nosis. In addition, there are signs of anaemia, debil- 
ity, a sallow unhealthy complexion, and various diges- 
tive derangements. Tenderness on pressure is evinced, 
but this does not occur to any great extent unless the 
peritoneal covering is involved. In protracted cases 
general dropsy sets in, with a murmur following the 
first sound of the heart. Sometimes the spleen may 
be greatly enlarged without any marked disorder of 
the general health, with the exception of debility. 

Treatment. — When the enlargement is the result of 
ague, change of climate and quinine are essential. In 
other cases steel and the bromide of potassium are 
serviceable. Arsenic is recommended in cases where 
there is no fever or periodicity. It can be con- 
veniently given in the form of the iodide in T ^ gr. 
doses, accompanied or followed by iodide or bromide 
of potass, or both (F. 5). 



214 leucocythjemia. 

Leucocyth^mia. 

Dr. Hughes Bennett, of Edinburgh, first directed 
attention to this affection in 1848/ and six weeks 
afterwards Professor Virchow detailed another case 
where similar phenomena were observed in the blood. 

Dr. Bennett called the disease leukaemia or white 
blood, and imagined it was due "to suppuration of 
the blood without inflammation." He subsequently 
modified this view and called the disease leucocyt- 
hsemia (huxos white, xuroq a cell, and ai/ia blood), 
white-cell blood. 

Pathology. — The pathology of the disease to a cer- 
tain extent is expressed by the name, as there is a 
great increase of the white corpuscles of the blood, 
while the red ones are diminished. If an ounce of 
leucocythsemic blood, freed from fibrin, is placed in 
a glass, the red corpuscles sink to the bottom, while 
the colorless constitute the white milky upper stratum. 
Microscopically the excess mentioned is confirmed, and 
is more marked w T hen the red corpuscles accumulate 
in rouleaux, leaving clear spaces filled with the color- 
less ones. The specific gravity is reduced. The dis- 
ease is always associated with hypertrophy of one or 
more of the lymphatic glands, or of the spleen, or of 
both together. It is also sometimes associated with 
changes in the medulla of bone. 

Symptoms. — Great pallor evidences leucocythsemia, 
and with the pallor there are weakness and emaciation, 
gradually increasing until death occurs. Ascites from 
the enlargement of the liver, spleen, or both, accom- 



BR0NCH0CELE, GOITRE. 215 

panics diarrhoea; epistaxis, urine loaded with uric 
acid, nausea, and jaundice, have also been noticed in 
cases which have come under observation. There 
may also be haemorrhages from the bowels and urinary 
passages. 

Treatment. — No remedy seems of any special avail 
in this disease. Of tonics, iron and quinine have ap- 
peared most serviceable (F. 77, 75). Good nourish- 
ing food should also be given. Diarrhoea and haem- 
orrhage should be treated as they arise, by appro- 
priate remedies. 

Bronchocele, Goitre, 

Consists essentially in hypertrophy of the normal 
constituents of the thyroid gland, viz., the blood- 
vessels, the connective tissue, and the groups of inter- 
communicating vesicles. Sometimes these are all in- 
creased in proportion; the enlargement is, however, 
generally at the expense of the connective tissue and 
the vessels. The size varies from mere fulness to that 
of a cocoanut. 

It is peculiar to certain localities, and constitutes 
the goitre of the Swiss and the Derbyshire neck of 
England. It is also found in Nottinghamshire, Sus- 
sex, Yorkshire, and seems in all cases to depend on 
the water supply being greatly impregnated with the 
sulphate and carbonate of lime, with the addition also, 
according to Virchow, of some endemic malarial in- 
fluence not dependent on any of the causes mentioned. 

A peculiar enlargement of the thyroid body, occur- 
ring chiefly in young women, and associated with pal- 



216 addison's disease. 

pitation of the heart, uterine and menstrual derange- 
ments, and prominence of the eyeballs (exophthalmos), 
is termed Graves's or Basedow's disease. 

Symptoms. — The enlargement is characterized by 
no pain. It is simply inconvenient by its bulk, which, 
however, may be attended with serious symptoms if 
there is pressure on the large veins, sympathetic, pneu- 
mogastric, or recurrent laryngeal nerves, or if the 
oesophagus or trachea is compressed. 

Treatment — In the endemic form the patient should 
be removed to another situation, and iodine and its 
preparations externally and internally should be given. 
Tincture of digitalis is useful for the excessive palpita- 
tion, in the exophthalmic form, or belladonna com- 
bined with iron. 

In very severe cases operative measures, as passing 
a seton through or even extirpation of the gland, have 
been recommended. 



Disease of the Suprarenal Capsules, 
Addison's Disease. 

The function of the suprarenal capsules is a subject 
of great interest and obscurity. Their purpose in 
the economy of nature is as yet undetermined. They 
seem, like the spleen, the thymus, and the thyroid 
glands, to be essential in a -healthy state to the proper 
elaboration of the blood, and when diseased they lead, 
according to the investigations of the late Dr. Addi- 
son, to a peculiar series of phenomena. The convic- 
tion seems to have grown on Dr. Addison, that the 



DISEASES OF KIDNEY. 217 

suprarenal capsules were implicated, by observing 
that a peculiar form of anaemia with discoloration of 
the skin was not connected with disease of other organs 
usually associated with anaemia. The symptoms ob- 
served by him were great and increasing debility, a 
feeble pulse, faintness on the slightest exertion, loss of 
appetite, a pain in the epigastrium, shooting through 
also between the scapulas, and progressive emaciation. 
With these general symptoms the skin became gradu- 
ally discolored ; this discoloration being most marked 
in the face, neck, superior extremities, penis, scrotum, 
and round the navel. The skin in the regions men- 
tioned, and also in the hands, assumed a dingy, 
smoky hue, which in advanced cases deepened into a 
"bronzed" color. So marked was this in one case 
recorded by Dr. Addison, "that, but for the features, 
the patient might have been mistaken for a mulatto." 

Cases of Addison's disease progress to an unfavor- 
able termination, and the " bronzing" of the skin in- 
creases with the general debility. 

Treatment. — Xo treatment seems of any avail. 



DISEASES OF THE KIDNEYS. 

The quantity of urine passed in twenty-four hours 
in health is two pints and a half, or from forty to fifty 
ounces ; in color it is pale yellow, in reaction acid. 
The specific gravity is from 1020 to 1025, and is de- 
termined by an instrument termed the urinometer. 



218 DISEASES OF KIDNEY. 

What is meant by specific gravity is at once seen by 
placing the urinometer in distilled water, and after- 
wards in healthy urine. It will be observed in the 
one case that the instrument floats at zero, while in 
the other at the figures mentioned before. The taking 
of the specific gravity is an important and essential 
step in determining the nature of diseases of the kid- 
ney; for if below the figures mentioned, there is 
probably albumen, if above possibly sugar. 

Healthy urine freshly passed and examined with 
the microscope is absolutely structureless ; allowed to 
stand for twelve hours a slight cloudy precipitate may 
be observed, which, on microscopic examination, re- 
veals a few epithelial scales from the bladder, amor- 
phous urates, or a few crystals of triple phosphate. 

The appearances presented by the various deposits 
under the microscope are delineated in the e'ngrav- 
ings. 

1st. Epithelial scales. 

2d. Amorphous urates. 

3d. Triple phosphates. 

The amorphous urates consist of salts of potash, 
soda, and ammonia, in varying proportions. 

The triple phosphate is a combination of phosphate 
of ammonia and magnesia. 

Sometimes these deposits are present in what may 
be termed detectable excess, and it is necessary to as- 
certain the effect of reagents upon them, which may 
be summarized thus : 

Urine containing a superabundance of urates has 



DISEASES OF KIDNEY. 219 

a very acid reaction, and a pinkish-red deposit, which 
heat at once dissolves, leaving the urine clear. 

Urine containing phosphates has an alkaline re- 
action and a white deposit, which heat does not dis- 
solve, but on the contrary makes the urine examined 
cloudy; this cloudiness disappearing on the addition 
of a drop of nitric acid. 

The other crystalline deposits observed in urine are 
uric acid and oxalate of lime. 

The appearances presented by the former vary (see 
engravings), but they may be remembered by the fact 
that they are always colored either red or orange- 
yellow. 

Oxalate of lime crystals present an octahedral form 
(see engravings) sometimes of various sizes ; but rarely 
a dumb-bell appearance. Heat has no effect upon 
either of these deposits, but liq. potassse dissolves uric 
acid, not the oxalates, which require a mineral acid. 
All these deposits indicate no structural kidney dis- 
ease, but it is different when what are termed tube- 
casts are observed under the microscope. Of these 
there are five distinct kinds: 1st. Blood-casts or exu- 
dative; 2d. Desquamative or epithelial; 3d. Granular; 
4th. Fatty ; 5th. Waxy or hyaline casts. 

1. Exudative casts. 

These consist of the coagulated exudation or fibrin, 
and present a mould of the uriniferous tubes. The 
fibrin is poured into the tubes as the result of inflam- 
mation ; hence these casts are only seen in acute dis- 
eases of the kidney. 

2. Desquamative or epithelial casts consist of a 



220 DISEASES OF KIDNEY. 

cylinder of coagulable matter studded over with epithe- 
lial cells. 

3. Granular casts are usually small, and consist of 
the usual cylinder studded with small masses of fat, 
epithelium, oxalates, etc., giving a granular appear- 
ance, and being characteristic of the most chronic 
forms of Bright's disease. 

4. Fatty casts are the same as the preceding in their 
origin, only the cells have undergone fatty transfor- 
mation, and the casts have the appearance of being 
studded over with oil-globules. 

5. Waxy casts are clear glassy cylinders, present- 
ing the appearance of a structureless substance. 

It must be remembered that these three last forms 
of tube-casts are significant of chronic disease of the 
kidney, and may be seen in varying proportions on 
the same microscopical slide. 

Unhealthy urine may also contain pus and blood, 
detected by their respective appearances under the 
microscope. Urine containing pus also becomes, on 
the addition of liq. potass, thick, sticky, ropy, which is 
evident on attempting to pour it from one vessel to 
another; while urine having blood in any but the 
smallest quantity has a smoky or red appearance, and 
coagulates on being heated. 

The most important abnormal constituent in the 
urine is albumen, and it is essential that the tests for 
its presence there should be familiarly and practically 
known. For this purpose there are two great tests* 
heat and nitric acid. A test-tube should be filled to 
the depth of about an inch with the suspected urine, 



DISEASES OF KIDNEY. 221 

and heat applied by means of a spirit-lamp to its 
upper stratum until it boils, when, if albumen be 
present, it becomes turbid and cloudy in various de- 
grees. This cloudiness persists after the addition of 
nitric acid, and is thus distinguished from the phos- 
phatic cloudiness which is also occasioned by heat, 
but disappears on the addition of the acid. It is im- 
portant also to remember that if the urine is alkaline, 
heat will not affect the albumen and make it coagulate 
until a few drops of acetic acid have been added. 
The preliminary test for the acidity of the urine is 
essential, and also the addition of nitric acid after 
boiling, to distinguish between phosphatic and albu- 
minous cloudiness. 

Nitric acid alone is also an excellent test for albu- 
men. A test-tube being filled as before, and inclined, 
a little nitric acid is poured in so as to trickle slowly 
down the side to the bottom. If albumen is present 
three strata will be observed, one perfectly colorless 
of nitric acid at the bottom, another above this, coag- 
ulated albumen, and at the top the unaltered urine. 

Albumen having been detected in the urine leads 
to the inquiry, What significance has it, and with 
what diseases is it associated ? The answer to this is 

Acute and chronic Bright's disease of the kidneys, 
although it may also be found accompanying preg- 
nancy, any of the febrile diseases, heart or lung affec- 
tions, or cirrhosis of liver. 



19 



222 DISEASES OF KIDNEY. 



Nephritis. 

Previous to entering on Bright's disease, it is nec- 
essary to mention that the kidney, like other organs 
of the body, may be the seat of congestion, which may 
terminate at that stage, or go on to inflammation, and 
constitute what is termed nephritis. Nephritis is, 
however, rare. Congestion may be the result of ex- 
posure to cold, of overdoses of special drugs, such as 
cantharides or turpentine, or it may appear during 
the various febrile and inflammatory diseases. It 
may be then considered active congestion ; while if it 
results in consequence of cardiac or pulmonary disease 
interfering with the general venous circulation, or 
from pregnancy, or tumors pressing on the renal 
veins, or inferior vena cava above, then it is consid- 
ered a passive congestion. Following from some of 
the above causes, or from the direct irritation of a 
renal calculus or embolus, or from inflammation of 
the bladder creeping along the ureter to the pelvis, 
infundibula, and calyces, the condition termed pyelitis, 
or inflammation of the lining membrane of the kid- 
ney, may be excited. The mucous membrane thus 
becomes congested, thickened, softened, and from its 
free surface is discharged mucus containing epithelium, 
pus-corpuscles, and sometimes blood. If this affection 
is persistent, suppuration may be established, false 
membranes formed, and ulceration take place, not 
merely in the mucous membrane but also in the sub- 
stance of the kidney. This may be designated " sup- 
purative nephritis." Supposing that the pus can 



DISEASES OF KIDNEY. 223 

escape easily by the ureter, and that one kidney is 
alone affected, the mischief may continue for years 
with little except local uneasiness, and it may ulti- 
mately become quiescent. In other cases, and whether 
or not the ureter is obstructed, an abscess may form, 
enlarging and burrowing in all directions, sometimes 
penetrating the diaphragm, pointing in the loins, 
bursting into the peritoneum, or descending along the 
psoas muscle and pointing under Poupart's ligament. 

Symptoms. — Pain and tenderness in the loins, in- 
creased by pressure or movement, irritability of the 
bladder, with the passage of urine clouded from the 
presence of blood, mucus, or albumen, characterize 
active congestion of the kidneys, — these phenomena 
being preceded by sickness and feverishness and thirst. 
These symptoms are intensified in pyelitis, and pus is 
also present in the urine; while if suppurative ne- 
phritis is established the local pain will be greatly in- 
creased, and rigor and hectic fever will accompany, 
with, in most cases, a typhoid condition, suppression 
of the urine, and death by exhaustion. 

Treatment. — In active congestion, if of independent 
origin, it is advisable to leech or cup the loins, and to 
follow this up by fomentations or the hot bath. The 
bowels should be kept freely open by a hydragogue 
cathartic, such as pulv. jalaps co., if the urine is slight 
in quantity. If the pain is great, opium may in some 
cases be given. The treatment of pyelitis or suppura- 
tive nephritis is based very much on ascertaining the 
cause, and endeavoring to support the strength. 



224 DISEASES OF KIDNEY. 

In chronic cases, astringents and mineral acids may> 
be given (F. 78). 

B right's Disease. 

The kidney has a thin translucent lightly-adhering 
capsule, and beneath this capsule is the kidney proper, 
containing a complicated and convoluted series of 
tubes lined with epithelium, and lying between the 
tubes, supporting and binding them, is a thin delicate 
web of fibrous tissue, and an abundant supply of 
bloodvessels to enable it to perform its secreting 
function. Each and all of these various parts may 
be affected with disease, but, as can be conceived 
from the intimate union existing between them, one 
cannot be affected without the other sympathizing, 
from whatever may be the original starting-point. 
Diseases implicating the tubes, fibrous tissue, and 
bloodvessels, thus merge into one another. 

The name Bright's disease is deservedly given in 
honor of the illustrious physician of Guy's Hospital, 
who, in 1827, threw the segis of his name round all 
kidney affections associated w T ith albumen in the urine. 
Bright's disease may be considered to be either acute 
or chronic. 

Acute Bright's Disease, under which term may 
be comprehended acute desquamative nephritis (John- 
son), acute tubal nephritis (Dickinson). 

The kidney is always enlarged, sometimes to twice 
its natural size, its capsule easily stripped off, its color 
usually deep red, at times mottled red and white, and, 



ACUTE BRIGHT'S DISEASE. 225 

.jcaoon thoro io hypcitmphy of the left " 
on being cut into, it drips with blood ; under the 
microscope there is observed an immense increase of 
the epithelial cells of the convoluted tubes, which are 
thus choked up to a greater or less extent, and com- 
press the renal capillaries, while the intertubular 
stroma is unaffected. From this condition it may 
pass on to recovery, or remain what will be afterwards 
described as the large white kidney; or the disease 
may terminate in death by dropsy and other intercur- 
rent affections, as pneumonia, pleurisy, and pericarditis. 

Causes and Symptoms. — It may be the direct result 
of cold or intemperance, or occur during convalescence 
from scarlet fever or other blood-poisons. Fever, 
pain in the loins, marked diminution of urine, which 
is albuminous, smoky colored, or dark brown from 
the admixture of blood, and of high specific gravity 
from disproportionate decrease of water to increase of 
solid constituents, characterize the early stages of this 
affection.* Dropsy supervenes. If a favorable ter- 
mination ensues, the urine becomes more abundant, 
the skin moist, blood, albumen, and tube-casts dis- 
appear, and convalescence and recovery are estab- 
lished in a varying interval of weeks or months. A 
large proportion — Frerichs says two-thirds — recover. 

Treatment is based on obvious principles to induce 
perspiration and to relieve the overloaded tubes. 
Hence a warm blanket bath may be employed, the 
blanket being wrung out of warm water and wrapped 
round the patient, while an abundance of water 
should be drunk, and a mixture of acetate of potass, 



226 DISEASES OF KIDNEY. 

citrate of potash, and infusion of digitalis, ordered 
(F. 37). The bowels should also be freely acted on 
by jalap or elateriura (F. 27). 

Locally, dry-cup the loins and apply hot linseed- 
meal poultices. The diet should consist of milk, beef 
tea, or nourishing soups. During convalescence all 
exposure to cold should be avoided, the wearing of 
flannel insisted on, and a mild preparation of iron, by 
preference the ammonio-citrate, given (F. 90). Change 
of air is also beneficial. 

Chronic Bright's Disease. — Three chief types 
are recognized as post-mortem appearances of those 
dying of chronic Bright's disease: 

A. — Kidney smooth, white, and enlarged, as re- 
sulting from previous disease. The cortical substance 
is increased, capsule easily stripped off, while on the 
white or mottled surface " conspicuous stellate patches 
of bloodvessels are seen." Microscopically, the epithe- 
lial lining of the tubes is swollen, the tubes distended, 
and the cells opaque and granular, and often loaded 
with oily particles. The intertubular stroma is un- 
altered. 

B. — Kidney granular, brown or brownish-red, small 
and contracted. The capsule is adherent, requiring 
force to peel it off; the fibrous stroma is increased, 
and cysts are frequently developed, most probably 
through obstruction to the uriniferous tubes. Dr. 
Bright's original description of this kidney is as fol- 
lows: "The kidney is rough and hard and gives re- 
sistance to the knife in attempting to cut into it. 
Numerous projections are seen to rise on the surface 



THE LARGE WHITE KIDNEY. 227 

not much exceeding a pin's head. The tabular por- 
tions appear to be drawn near the surface. It ap- 
pears to be, in short, like a contraction of every part 
of the organ, with less interstitial deposit than in the 
last variety." 

Further, he indicates his belief that this second 
variety is but a modification of the first, an advanced 
stage of one and the same disease — an opinion enter- 
tained by most German pathologists, but not yet ac- 
cepted by English authorities. 

C. — Waxy or lardaceous kidney, amyloid degen- 
eration. 

In well-marked cases the kidney is enlarged and 
smooth, and on section the cortex is bloodless, of a 
white or yellowish color, with a waxy smooth ap- 
pearance like bacon rind or w T hite beeswax. In other 
cases the organ may be small. The degeneration 
seems to affect first the Malpighian bodies and small 
arteries, and to be follow-ed by transudation of fibrin 
into the tubules, w r ith subsequently, in some cases, 
atrophy. The proper test for this degeneration is 
iodine, which imparts when applied a deep mahogany- 
brown color to the parts affected, while it merely 
stains yellow 7 the portions unimplicated. 

The clinical history, course, and symptoms of these 
three forms vary. 

The Large White Kidney, 

Following on the acute form or having a latent un- 
detected origin, is attended with dropsy, the counte- 



228 DISEASES OF KIDNEY. 

nance being puffy and pasty. The urine is scanty, 
containing casts, epithelial, fatty, or hyaline ; and the 
specific gravity normal or rather high, with albumen 
always present. 

The average age of the patient is twenty-eight 
years. Recoveries and relapses are frequent. In fatal 
cases the ordinary duration of the disease is under six 
months, and in exceptional cases it may extend over 
some years. 

The Granular Contracting Kidney 

Is associated with middle age, not youth, being most 
common about fifty years, and more frequently ob- 
served in males than females in the proportion of two 
to one. Its commencement is insidious, the early 
symptoms slight, the progress slow, and the disease 
may run a latent course for months or years. Fre- 
quent micturition and some slight puffiness of the 
ankles lead to an examination of the urine, which is 
found to be copious in quantity (three to four pints), 
of low sp. gr., and with a comparatively small quan- 
tity of albumen. In later stages the urine becomes 
scanty and the albumen more abundant. The gen- 
eral health gives way, the pallor becomes pronounced, 
chest and stomach derangements increase, and death 
ensues through exhaustion, or with symptoms of 
oedema of the lungs, uraemia, or other intercurrent 
affection. How the chronic nature of the disease 
gives rise to increase in the heart's structure is as yet 
an undetermined question ; still in nearly fifty per 



THE WAXY KIDNEY. 229 

cent of the cases there is hypertrophy of the left 
ventricle, and also a peculiar form of retinitis. Tube- 
casts are few in number, being either hyaline or finely 
granular. 

The Waxy Kidney 

Is associated usually with amyloid disease of other 
organs, as liver or spleen, and with a previous history 
of syphilis, caries, phthisis, long-continued suppura- 
tion, or other exhausting condition. It is character- 
ized by a large flow of urine, 100 to 200 ounces being 
passed in a day. The urine has a low sp. gr., with 
few tube-casts, generally hyaline in character. The 
albumen is at first slight, but as the disease advances, 
the urine, as in the previous form described, becomes 
of higher sp. gr., and the albumen more abundant. 
Dropsy does not, until the late stages have been 
reached, form a prominent feature of the disease. 

The disease may not be recognized at first, and 
hence may extend over a series of years. Indeed, it 
seems to form a part of various constitutional states, 
and upon these its ultimate issue depends. 

Treatment of the various forms of chronic Bright's 
disease requires careful management, though based 
on certain obvious principles, hygienic, dietetic, and 
medicinal. 

All exposure to cold should be avoided, and, if 
circumstances permit, a residence selected in a mild 
and sheltered spot, or, what is still better in the more 
chronic forms, a sea voyage should be made. The 

20 



230 DISEASES OF KIDNEY. 

patient should be habitually clothed in flannel, moder- 
ate exercise insisted on, and an occasional use of warm 
baths and frictions to the skin. 

Milk agrees well, and may be taken ad libitum. All 
spirits should be forbidden, but two or three glasses 
of claret or beer are permissible daily. 

The constant draining away from the blood of one 
of its most important constituents necessitates the ad- 
ministration of strengthening medicines, and expe- 
rience has shown iron to be the best of these. The 
tincture often causes headache, and hence the citrate 
of iron and quinine, or the syrups of the phosphate 
or iodide of iron, are recommended, and should be 
steadily persevered in (F. 76). No medicine seems 
as yet discovered to have any effect in diminishing 
directly the quantity of albumen, and hence other 
treatment must be symptomatic. Dropsy is the chief 
symptom, and the most effectual way to combat the 
dropsical effusions is by means of hydragogue cathar- 
tics and warm baths ; the patient entering the bath 
at a temperature of 98°, which is gradually raised to 
108°, and remaining in it for half an hour, when he 
returns to bed and is enveloped in blankets. Com- 
pound jalap powder and bitartrate of potash may be 
ordered twice or thrice a week, or Friedrichshall or 
Hunyadi Janos water. More active means of the 
same nature are found in gamboge and elaterium 
(F. 27). 

Opinions vary greatly as to the value of diuretics, 
but Christison recommends digitalis, and Rayer horse- 
radish tea. 



UREMIA. 231 

In extreme dropsy punctures or incisions may be 
made into the skin of the legs or scrotum. 

Mercury, in any of its forms, is contraindicated by 
most authorities. It rapidly produces salivation and 
most untoward consequences. 

Ukjemia. 

In the course of Bright's disease, or any other state 
attended with albumen in the urine, a group of phe- 
nomena termed unemic, are sometimes presented, 
owing, it is supposed, to a poisoned state of the blood. 
Generally they begin insidiously with headache and 
dimness of vision, followed by convulsive paroxysms, 
profound insensibility, stertorous breathing, pale face, 
and dilated pupils. In exceptional cases conscious- 
ness is not wholly lost, and the patient can be roused 
from the deep drowsiness by being spoken to or 
shaken. In these cases there may be some chance of 
recovery, but in others, when the coma is complete, a 
fatal issue is almost certain. 

Much controversy and many theories have been ex- 
cited by uraemia. The original idea of Willis was that 
the special poison in the blood was urea. Frerichs 
supposed that urea is harmless, and that its conversion 
into carbonate of ammonia occasioned the ursemic 
phenomena. The more recent experiments of Oppler 
and Zalesky indicate that neither of these theories is 
correct, but that the chief poisonous agents are the 
accumulation in the blood of the first products of tis- 
sue-change, creatin, creatinin, and other extractives, 



232 DISEASES OF KIDNEY. 

which are converted in the kidneys into urea and 
uric acid. The question is as yet not satisfactorily 
determined; for, though the phenomena observed dur- 
ing life are plain enough, yet the absence of anatomi- 
cal changes in the chief nervous centres must render 
the explanation of these a matter of theory and un- 
certainty. 

Treatment — All that we can do is to try and in- 
crease the flow of urine by diuretics, and awaken the 
action of the skin by diaphoretics (F. 35, 31). Inha- 
lation of chloroform may modify the severity of the 
convulsions; an injection of chloral may also be tried. 
Should the attack be sudden, and the blood not greatly 
impoverished, as sometimes happens in pregnant wo- 
men, free venesection has much to recommend it, and 
should not be dismissed as absurd simply because it 
was the panacea of our forefathers. 

Chylous Ueine 

Was first recognized and described by Dr. Prout, 
and has since been investigated by other observers. 
The urine is milky when voided; then coagulates into 
a tremulous mass like blanc-mange; then liquefies into 
a creamy scum with a brownish sediment. The urine, 
in fact, presents those characteristics which would re- 
sult from the admixture of normal urine and normal 
chyle. It contains fibrin, albumen, fat in a molecular 
form like the fat of chyle, and occasionally a small 
proportion of red corpuscles. 



HEMATURIA. 233 

No casts have, however, been detected; and the fat 
chiefly characterizes the urine passed after meals. 

Chylous urine is more common to tropical than 
temperate climates, to adults than to children, to fe- 
males than to males. 

Its presence is not inconsistent with good health. 
Intermissions are frequent. After lasting some time, 
it may disappear for years,' or even for life. 

Pathology. — Dr. Prout imagined it to be due to a 
faulty assimilation, by which the chyle was permitted 
to mingle with the blood; and combined with this 
was some renal disorder, by which the kidneys per- 
mitted the chyle to transude and mingle with the 
urine. The blood examined, however, presents no 
signs of chyle, and post-mortem examination reveals 
no disease of the kidneys. 

Dr. Roberts says it is due to vesicular dilatation, 
and rupture of portions of the lymphatic vessels 
situated on the mucous surface of the bladder or 
urinary tract. 

• Treatment. — Numerous remedies have been sug- 
gested, and have failed in doing good, as can easily 
be imagined if Dr. Roberts's explanation is the cor- 
rect one. Rest and local astringents are advisable, 
with tonics to combat the anaemia (F. 78). 

HEMATURIA, 

As its name implies, means the admixture of blood 
with the urine ; and this mixture is easily recognized 
by the color it imparts to the secretion, unless the 



234 DISEASES OF KIDNEY. 

quantity is very small, when it may require the aid 
of the microscope to detect it. Blood in the urine may 
originate from different sources, which, as a general 
rule, can be recognized from the following considera- 
tions. If from the kidneys it is found equally dif- 
fused, giving to the urine a smoky-reddish tint, and 
after standing awhile a grumous-colored deposit sub- 
sides. If from some other part of the urinary tract — 
e. g. y if it comes from the ureter, bladder, or urethra — 
the color is more bloody, more red, and frequently 
distinct clots are observed in the deposit. All urine 
containing blood is necessarily more or less albu- 
minous. 

By far the most common cause is congestion, due to 
some blow or injury in the renal region. It may also 
arise from acute Bright's disease, from malignant dis- 
ease of the kidney or bladder, from the presence of a 
calculus either in kidney, ureter, or bladder ; or from 
the taking of irritating medicines, as turpentine or 
cantharides. Sometimes it is symptomatic, and de- 
pendent on other than urinary diseases. Thus it is 
seen in purpura and scurvy; or it may be found in 
yellow fever, cholera, or any of the eruptive fevers ; 
and when detected in the course of these diseases the 
prognosis is most unfavorable. At other times it is 
supplementary to a normal state or diseased condition, 
e. g., it may accompany menstruation in a woman, or 
a hemorrhoidal flux in either sex. The endemic 
hematuria of the Mauritius and Brazil is dependent 
on the presence of a small parasite which infests the 



H^IMATINURIA. 235 

mucous membrane of the pelvis of the kidney or 
bladder. 

Haemorrhage from the bladder, due to acute cystitis, 
fungoid growth, or calculi, is usually recognized by 
symptoms referred to that organ, viz., very frequent 
micturition and pain in the hypogastrium. Urethral 
haemorrhage is known by the escape of blood during 
the intervals of micturition. 

Treatment will vary with the causes and circum- 
stances of the haemorrhage, but when our object is to 
treat the hematuria for itself — to stay the loss of 
blood — perfect rest is absolutely necessary, and the 
application of ice to the seat of the haemorrhage. 
Thus if the kidneys are the seat, put ice poultices to 
the loins ; if the bladder, to the epigastrium and 
perineum. With the local application of ice give 
astringents internally, e.g., acetate of lead, gr. iij, pulv. 
opii, gr. J, in a pill every two hours, until six or eight 
doses have been administered ; or ergotin may be in- 
jected subcutaneously. 

In severe vesical haemorrhage a solution of alum, 
20 grains to the pint of water, may be injected into 
the bladder. 

Hjemattnuma 

Is a curious disorder, to which attention was first 
drawn by Dr. George Harley in 1865. The peculiar 
feature of the disease is the paroxysmal passing of 
dark-colored urine, containing not blood, but merely 
the coloring-matter of the blood — haematin. A sense 
of shivering or cold about the loins precedes the par- 



236 DISEASES OF KIDNEY. 

oxysm. The intervals between these are irregular, 
and there is no certainty about their occurrence; for 
sometimes the urine at one micturition is clear, at 
another porter and bloody-colored. Microscopically, 
the urine presents chiefly an immense mass of amor- 
phous granular matter, with dark granular-colored 
tube-casts. The prognosis is favorable, though the 
duration of the disease cannot be defined. 

Treatment — During the cold stage send the patient 
to bed, and administer warm stimulating drinks. 
Tonics, as iron and quinine, are also indicated (F. 76). 

Gravel, Kenal Calculus, or Colic. 

Sometimes concretions of crystalline or amorphous 
sediments form in the pelvis of the kidney, and are 
accompanied with severe pain in their passage along 
the ureter to the bladder. There is also a frequent 
desire to micturate, retraction of the testicle, nausea, 
and vomiting, intense relief being obtained whenever 
the substance reaches the bladder. This may be termed 
a "fit of the gravel." When there is merely gritty 
matter or sand, no pain whatever may be experienced. 
The most common forms of gravel are the urates of 
ammonia, uric acid, the triple phosphates of ammonia 
and magnesia, or oxalates of lime. 

Treatment varies with the nature of the deposit. 
Vichy or Carlsbad waters and alkalies are useful when 
the urates predominate. If phosphates, the nitro- 
muriatic acid and a generous diet. If oxalates, dilute 
the urine by drinking plenty of cold water, which 



DIABETES. 237 

must not contain much lime, and avoid all saccha- 
rine substances. 

During the passage of a calculus employ a warm 
bath, afterwards poultices or fomentations to the loins, 
also give barley-water to drink, along with spiritus 
setheris nit. and vin. ipecac. To relieve the pain, 
morphia subcutaneously ; sometimes chloroform is 
necessary (F. 39, 40). 

In addition to the diseases mentioned, it mav also 
be stated in general terms that the kidney or kidneys 
may be attacked by cancer, either primary or second- 
ary, usually of the encephaloid form, and that the 
leading symptoms of the former are a tumor in the 
abdomen, sometimes very large, and hematuria ; that 
tubercle or hydatids may also originate in the organ, 
exhibiting in neither case very well-defined symptoms, 
though resulting fatallv in both; that when anv im- 
pediment exists to the flow of urine from the kidney, 
dropsy of the kidney, or hydronephrosis, may ensue, 
through dilatation of the pelvis, with atrophy of the 
cones or whole substance of the organ; and that, 
finally, one or both kidneys may be shifted from their 
original position, occasioning the condition known as 
movable kidneys. To enter, however, further into 
details would be foreign to the object of this handbook. 

Diabetes. 

The word diabetes, derived from the two Greek 
words, dia fiatvto^ literally means that the water is con- 
stant in running through the patient's system. Used 
literally diabetes may thus have a wide significance, 



238 DISEASES OF KIDNEY. 

but it is now employed as representing two distinct 
kinds of disease. In both there is an increased flow 
of urine; but in the one, diabetes mellitus, there is 
sugar in the urine, in the other, diabetes insipidus, 
this is absent. 

Diabetes insipidus seems to depend on unknown 
causes attacking by preference the male sex, usually 
between the ages of five and thirty. It has certain 
permanent and characteristic features, viz., an excessive 
flow of uncolored urine of low sp. gr., containing 
neither sugar nor albumen, and attended with a dry 
skin and great thirst. Its course is uncertain, and its 
treatment empirical. 

Diabetes mellitus, although it seems to have been' 
known in some measure to the ancient physicians, 
was practically unrecognized until Dr. Willis, in 1674, 
described it as a distinct disease; "for in it the urine 
differed from all other fluids of the body, as if it had 
been mixed with honey or sugar, and having a power- 
fully sweet taste. " Passing over subsequent years, it 
may be mentioned that Dr. McGregor, of Glasgow, in 
1837, discovered sugar in the blood as well as the 
urine, and that the stomachy formed saccharine matter 
instead of healthy chyle, which entered into the blood, 
and instead of forming fat, bone, and muscle, was 
passed into the system as sugar, and thence eliminated 
by the kidney. Claude Bernard, in 1848, opened up a 
new era in diabetes, when he pointed out that sugar 
was a normal secretion of the liver; and further, if 
the eighth pair of nerves are irritated at their origin in 
the fourth ventricle, sugar is produced in an abnormal 



DIABETES. 239 

quantity by the liver. Sugar could also be produced 
in various other artificial ways. It was supposed 
that the sugar thus formed in health was carried by 
the hepatic veins and inferior vena cava into the 
heart, and thence by the pulmonary arteries to the 
lungs where, combustion ensued, and the sugar was 
consumed. If, however, the quantity of sugar were 
considerably increased, either by faulty digestion or 
nervous irritation, the lungs were unable to perform 
their functions, sugar passed into the blood, and from 
thence found its way to the kidneys. 

Dr. Pavy's experiments led him to believe that the 
liver did not secrete sugar in health, but a substance 
termed hepatin; that the detection of sugar in the 
blood leaving the liver was a post-mortem, not a living 
reality; that if the hepatin were converted into sugar 
in diabetes, it was due to the curb being withdrawn 
from the liver, which was thus allowed, as after death, 
to run riot with its saccharine tendencies. 

Dr. Pavy thus disturbed the belief in Bernard's 
theory, as Bernard had engendered skepticism in 
McGregor's. 

Dr. Dickenson's theory supposes a dilatation of the 
arteries in the brain, followed by degeneration and 
excavation of the nervous substance in the neighbor- 
hood. He thus argues that diabetes has a nervous, 
not a digestive origin. 

It will thus be seen that no correct theory of dia- 
betes has yet been obtained; and this is not at all to 
be wondered at when post-mortem appearances are 
negative as to the special organ or organs at fault. In 

i 



240 DISEASES OF KIDNEY. 

a case of death from diabetes, which occurred lately 
in the Glasgow Royal Infirmary, there was no con- 
firmation of Dr. Dickenson's views; the only note- 
worthy fact in the examination being an unnatural 
softness and friability of all the organs of the body. 

Diabetes is best recognized by its symptoms, which 
are as patent as its pathology is obscure. The earliest 
symptoms which attract the patient's attention are 
thirst and hunger and the passage of a great quantity 
of urine. To these may be added a dry skin, a faulty 
digestion, a parched or often a red, flabby, or inordi- 
nately clean and wrinkled tongue, and progressive 
emaciation and loss of strength : the latter fact being 
in some cases rendered obvious by an inability or dis- 
inclination for sexual intercourse. The temperature 
is also low, and there is sometimes impaired vision. 
To this may be added the less important symptoms 
of constipated bowels, and change of temper, going 
on to a general gloominess. 

The urine passed may rise to 15, 20, 30 pints, or 
more, in the course of twenty-four hours, and it presents 
to the eye a pale color, while its odor is sweet like 
that of newmown hay, or that detected in a chamber 
containing apples. Its specific gravity is high, in all 
cases being above 1030, w T hile in some it rises to 1050. 

There are three distinctive tests for detecting sugar 
in diabetic urine : 

Moore 's Test — Add half the volume of liq. potass, 
to the urine. Boil in a test-tube, when the mixture 
assumes a dark- brown color. Healthy urine is only 
slightly darkened by the same proceeding. 



DIABETES. 241 

Trommers Test. — Place some of the urine in a test- 
tube, add a drop or two of solution of sulphate of 
copper, when a pale- blue tint is produced. Add to 
this liq. potass, in a portion equal to half the volume 
of urine, when a pale-blue precipitate of the hydrated 
oxide of copper is thrown down. Boil, and the result 
will be — 

1st. The dissolving of the first precipitate; 

2d. The throwing down of a yellowish-brown pre- 
cipitate of suboxide of copper. 

If there is no sugar there will be merely a black 
precipitate of common oxide of copper. 

Fehling's Solution. — A more delicate test consists 
in what is termed Fehling's solution — consisting of 
sulphate of copper, tartrate of potash, and caustic soda 
(F. 92). Boil a small quantity of the solution, then 
add a few drops of the urine, when, if sugar is abun-' 
dant, the same yellowish-brown precipitate as in the 
former case will result. If equal quantities of urine 
and of the test are used, and no change ensues, then 
there is not ^ of a grain of sugar present. 

Fermentation Test. — Take some German yeast and 
place it in a test-tube containing urine. Now invert 
the tube and place it upright in a saucer also contain- 
ing some of the urine. Placed at the side of the fire, 
or in a temperature of 80° Fahr., fermentation en- 
sues, carbonic acid is liberated, and collects in bubbles 
at the top of the tube. Xo change takes place in 
healthy urine. 

The average duration of diabetes, after its detection, 
is from one to three years in the young; in the old, it 



242 DISEASES OF KIDNEY. 

may be prolonged from five to twenty years. The 
prognosis is more grave in young subjects than in those 
after thirty. Various diseases may complicate dia- 
betes and hasten a fatal issue, as phthisis, pneumonia, 
bronchitis, carbuncles, abscess, gangrene, phagedenic 
ulcers, dropsy. Cataract, which is sometimes associ- 
ated with diabetes, seems due to the direct action of 
sugar on the crystalline lens. Lastly, inflammation of 
serous membranes of an asthenic type is a not unfre- 
quent complication. 

Treatment. — No drug seems to have any influence 
on diabetes. The diet must be carefully regulated. 
All substances containing sugar, or likely to produce 
sugar, should be avoided. A milk diet is by far the 
best, with animal food, fish, or eggs, and biscuits con- 
taining little or no starchy matter. Walker's Glas- 
gow, or Camplin's London, are best for this purpose. 
Of vegetables, cabbage and cauliflower may be occa- 
sionally allowed. Whisky or brandy, to the extent 
of two glasses daily, are the most suitable stimulants. 

The parched state of the mouth may be relieved, 
and perspiration induced, by wearing a respirator 
night and day, over which may be placed a knitted 
woollen cloth. 

Of medicines which are recommended, only one or 
two require mention. Opium and some opium alka- 
loids, codeia being best, are frequently prescribed, but 
require care from the tendencies to coma in some cases 
of diabetes. Alkaline and mineral springs, as Vichy, 
have been advocated, but these probably are only use- 
ful as diaphoretics, and thus merely temporary. 



DISEASES OF THE NERVOUS SYSTEM. 243 



DISEASES OF THE NERVOUS SYSTEM. 

We shall now attempt a brief description of dis- 
eases of the brain, and afterwards proceed to take up 
other affections connected with the nervous system. 
Insanity will not be spoken of except incidentally, as 
the subject is too special and complicated to be dealt 
with in a handbook such as this. The student must 
remember that our investigations of diseases connected 
with the nervous system are necessarily obscure dur- 
ing life, and that this obscurity is often not removed 
by post-mortem revelations. These so often clash, 
that any accurate classification seems at present du- 
bious. The following synopsis of diseases of the 
brain may be found serviceable : 

1. Cerebral amemia, from discharges of blood, and 
also from poor living. 

2. Cerebral congestion, active or passive, as in dis- 
eases which obstruct the circulation, as tricuspid in- 
sufficiency, etc., etc. 

3. Embolism and thrombosis, occluding the vessels 
at a point beyond the circle of Willis. The area sup- 
plied by the occluded vessels is at first pale, and then 
tinged, from the back flow of blood into if leading to 
red softening, and the subsequent degenerations of the 
tissue in the area. 

4. Diseases in which the vessels burst, and which 
result in bleeding; e.g., fatty degeneration of the walls 
of the vessels, miliary or larger aneurisms; diseased 
states of the blood, as purpura, etc. 



244 DISEASES OF THE NERVOUS SYSTEM. 

5. Inflammation of the membranes. Meningitis 
may be — 1. Simple acute; 2. Simple chronic; 3. 
Tubercular. 

6. Inflammation of the brain- substance, or ence- 
phalitis, or local inflammation, often followed by- 
abscess. 

7. Tumors, especially syphilitic. 

8. Gray degeneration of the nerve-tissue of the 
brain and spinal cord, with increase of the interstitial 
tissue in areas here and there. 

9. Dropsy of the brain and membranes, hydroceph- 
alus, etc., etc. 

Cerebral Anemia. 

In cases of death from cerebral anaemia, a pale 
color of the brain is observed, most marked in the 
gray substance, but also making the white matter 
look more pale than normal. There is also an absence 
of the usual red points, combined with a diminished 
quantity of blood in the vessels. 

Symptoms. — -Giddiness, ringing and buzzing in the 
ear, paleness of the face, faintness and loss of con- 
sciousness, characterize the lighter forms of cerebral 
anaemia, as in the faintness which attacks the student 
on his first sight of an operation. The graver forms 
may be due to sudden haemorrhage, and may be at- 
tended with convulsions and coma. The state of the 
pupils is first contraction, next dilatation, and, finally, 
the normal condition if the issue is to be favorable. 
By many authorities, death from sudden shock is con- 
sidered as due to cerebral anaemia. 



CEREBRAL CONGESTION. 245 



Cerebral Congestion 

May be cither active or passive, and certain appear- 
ances, which may, however, be all or in part absent, 
are observed on post-mortem examination. In the 
active form the capillaries and large bloodvessels of 
the brain and pia mater are increased in size, hence 
the blood-points are observed to be larger and more 
numerous than usual, while the pia mater has a red 
or rose-colored appearance, in spots, or throughout its 
whole extent. The gray matter is red or violet in hue, 
the choroid plexuses are enlarged, and the ventricles 
contain an excessive amount of fluid. In the passive 
form, when the quantity of venous blood is augmented, 
the veins generally are distended. 

Symptoms. — In the active form there is pain, dizzi- 
ness, and confusion of the intellect, which may last 
from half an hour to two or three days; sleeplessness, 
irritability of temper, and inability to do any mental 
work, with a sense of flying heat shooting over the 
head and neck, and redness of the face, are also prom- 
inent symptoms. In the passive form there is the 
same confusion of ideas, but with mental torpor in- 
stead of irritability, and drowsiness instead of sleep- 
lessness. In the very severe forms there may be loss 
of consciousness, or delirium, or convulsions. The 
slight forms are rarely dangerous in themselves, and 
may be recovered from under treatment. In the severe 
forms the prognosis is grave, and when death occurs 
it is during coma. 

Treatment. — General bloodletting, once so common 
21 



246 DISEASES OF THE NERVOUS SYSTEM. 

in cerebral congestion, is now abandoned, except in 
cases attended with delirium. Local leeching behind 
the ears is in some cases advisable. The object of 
treatment is to draw blood away from the head, hence 
quickly acting purgatives, such as croton oil, or calo- 
mel and jalap, are employed; while, at the same time, 
mustard and vinegar should be rubbed on the legs 
and arms, or the feet may be placed in a warm bath. 
In the lighter cases ice should be applied to the head. 
The diet should be light, and all alcoholic stimulants 
forbidden. Bromide of potassium and ergot are recom- 
mended by Hammond, followed by strychnia (F. 7 1 a). 
In cerebral anaemia a horizontal position is indi- 
cated, with nourishing soups and wine, and the avoid- 
ance of all mental disturbance. Tonics containing 
quinine and iron are also useful. 

Cerebral Embolism and Thrombosis. 

If the occlusion, the shutting up of a vessel in the 
cerebral circulation, is due to a something being carried 
away from a distant part of the system and lodged at 
the point of occlusion, we say it is due to embolism. 
If, on the other hand, a clot is formed locally at the 
spot occluded, we consider it is the result of throm- 
bosis. The result in either case will be the same to 
the substance of the brain unless the obstruction be 
removed. It must lead to deficient supply of nourish- 
ment in that particular place, to softening, and to the 
loss of functional power in the parts thus deprived of 
their nutriment. The symptoms which, however, 



CEREBRAL HAEMORRHAGE. 247 

characterize the first step of the occlusion — the wedg- 
ing in — vary somewhat. In embolism the onset is 
sudden ; there are no premonitory warnings, but rapid 
giddiness, or an involuntary cry, or immediate loss of 
consciousness. In thrombosis the symptoms are slowly 
developed, preceded by pains in the head, general 
confusion, loss of memory, perhaps numbness, and 
these show the occlusion is complete, that the vessel 
is fairly dammed up. The further symptoms between 
the two must be the same, being dependent on the 
same circumstances. Hemiplegia may follow, or the 
paralysis may only affect the tongue, or there may be 
simply a loss of the faculty of speech. Further, it 
may be mentioned that thrombosis is usually asso- 
ciated with advanced age and feebleness of the heart's 
action ; while in embolism there is valvular disease of 
the heart, which, of course, may occur at any age. 

Cerebral Hemorrhage. 

Cerebral hcemorrhage, by which is meant extrava- 
sation of blood in the substance of the brain, depends 
essentially, according to recent authorities, on miliary 
aneurisms, which appear as little globular masses in 
the small intracranial vessels, and are due to a diffuse 
arteritis proceeding from without inwards. Although 
this statement may in the main be true, yet haemor- 
rhage may also arise from softening of the cerebral tis- 
sue, from atrophy of the brain-substance, and from 
tension of the bloodvessels, the result of mental and 
physical causes. In the majority of cases the seat of 
cerebral haemorrhage is the corpora striata, the optic 



248 DISEASES OF THE NERVOUS SYSTEM. 

thalami, the crura cerebri, and the medulla oblongata, 
on the right side more frequently than the left. The 
blood poured forth, varying according to the causes, 
dislodges part of the brain-substance and a cavity is 
produced. If death does not occur, the further be- 
havior of the extravasated blood is the absorption of 
the serum, the contraction and hardening of the red 
corpuscles and the fibrin, the contraction of the cavity, 
and eventually the formation of a cicatrix which in- 
closes the remains of the clot. At other times the 
cavity does not contract, but remains distended with 
blood, and forms the nidus for secondary lesions, fresh 
haemorrhage, or abscess. 

Symptoms. — Often previous to the attack a group of 
symptoms may forewarn the patient, as sudden diffi- 
culty of speech, defects of vision, dizziness, faintness, 
sickness. There may, however, be none of these pro- 
dromata, the patient being struck down abruptly, as 
if shot, and rendered thoroughly unconscious, with 
loss of sensibility and power of motion ; the breathing 
stertorous, lips and cheeks puffed out with expiration, 
the pupils * largely dilated and insensible to light. 
After a time, if death does not occur, consciousness 
returns, the patient attempts to turn in bed, and en- 
deavors to speak. He finds, however, that articula- 
tion is indistinct, that the muscles of one side of the 
face are paralyzed, and the power of motion of the 
limbs and body of the opposite side is lost. 

The temperature is found at first to be low, 96.8°, 
next normal, 98.5°, so continuing if recovery is to be 



CEREBRAL HEMORRHAGE. 249 

complete; but if a fatal result is to ensue, it will rise 
markedly to 104° or 106°. 

There is another form of cerebral haemorrhage un- 
attended with unconsciousness, and in which the 
patient is sensible of his condition but unable to avert 
the hemiplegia which ensues. 

Causes. — A long list of exciting causes may be 
made out. It will suffice simply to mention drunken- 
ness, excessive venery in old people, extreme joy or 
anger, and straining at stool. It is also found that 
winter is more favorable to the occurrence of cerebral 
haemorrhage than summer, and that neither a thin nor 
plethoric frame, neither poverty nor riches, specially 
provoke it. The chief predisposing causes are diseases 
of the heart and vessels, and an occupation necessitat- 
ing great exertion. 

Prognosis. — In the severe seizures death may occur 
within a few hours, in the less severe about one-third 
of those attacked die; while in the mild form the prog- 
nosis is generally favorable, although the patient can- 
not be considered free from danger until after the 
eighth day. 

Treatment. — If there are any forewarnings the bow T els 
should be opened by a brisk purgative, the head kept 
cool and well raised, every mental strain avoided, and 
the bromide of potassium given in thirty-grain doses. 

During the attack, symptoms should be met as they 
arise. If the bowels have not been recently opened, 
place two drops of croton oil on the tongue; if the 
urine is not passed naturally, draw it off with a 
catheter ; if haemorrhage is still supposed to be going 



250 DISEASES OF THE NERVOUS SYSTEM. 

on, inject ergotin subeutaneously. The patient should 
also be kept quiet, with the head well raised, and in 
a well-ventilated room of an even temperature. 

After the eighth day remedial measures may be put 
in force to restore the power of motion and prevent 
contraction. The agents best suited for this purpose 
are passive motion, strychnia, phosphorus, and elec- 
tricity (F. 85). 

Apoplexy 

Is a term significant chiefly of a prominent symptom 
in the last three affections of the brain described — 
embolism, thrombosis, and cerebral haemorrhage. It 
denotes a clinical fact, a stroke, a beating down sud- 
denly ; and as this was accompanied by loss of con- 
sciousness and motor power, with stertorous breathing 
and peculiar countenance, older writers attempted to 
establish, and did name as a disease what is in truth 
only a symptom. They distinguish between several 
varieties, as sanguineous, nervous, and serous apoplexy. 
This nomenclature has now been abandoned, and the 
various clinical phenomena are classified under the term 
" an apoplectic attack." The question may be asked, Is 
it possible to distinguish between the causes which may 
produce this ? The answer to this question is simply 
a matter of conjecture, although the following consid- 
erations bear somewhat pertinently on the point. 
Haemorrhage is much more frequent than thrombosis, 
and may be said to be rare under forty. The attack 
may be supposed to be due to embolism if occurring 
below that age, especially if there be evidence of valv- 



APOPLEXY. 251 

alar disease of the heart, and if the well-marked 
hemiplegia at first accompanying it disappear within 
a few days. 

A person may, however, be discovered in an un- 
conscious state, resembling an apoplectic seizure, and 
it is of great importance that a diagnosis should, if 
possible, be clearly established, as serious mistakes 
may otherwise occur. This unconsciousness may be 
due to drunkenness, to uraemia, to narcotic poisoning, 
to epilepsy, or to concussion from a fall or blow. In all 
cases the history will form a marked determining dis- 
tinction, and especially is this true in the two last; 
for if dependent on epilepsy, the attack will not be 
long, and there will be an account of former seizures; 
if from concussion, there may be injuries or bruises on 
other parts of the body, probably bleeding from the 
ears or nose, and other circumstances tending to the 
supposition that the insensibility is due to wilfulness 
or accident. In drunkenness the patient can be 
aroused to some extent, the insensibility not being 
complete; there is no hemiplegia, and the smell of the 
breath will betray alcohol ; yet as drunkenness and an 
apoplectic seizure may exist together, the diagnosis 
should be guarded, and if a doubt exists it is better 
to err on the safe side and act as if they were com- 
bined. In uraemia there is no hemiplegia, the urine, 
if drawn off by a catheter, will be found to be albu- 
minous, and there will in all probability be indica- 
tions of dropsy in other parts of the body. 

In narcotic poisoning the pupils are contracted, with 



252 DISEASES OF THE NERVOUS SYSTEM. 

no hemiplegia, no remissions in the insensibility, but 
on the contrary deepening coma. 

In all doubtful cases it is advisable to use the 
stomach-pump. 

Cerebral Softening. 

Cerebral softening may be caused either by anaemia 
or inflammation, and is a result of some of the lesions 
already described, or it may proceed without any of 
them, as, for instance, from long-continued intellectual 
exertion or mental emotion. It is most apt to occur 
between fifty and eighty. Cerebral softening, the re- 
sult of anaemia and due to imperfect nutrition of the 
part affected, is designated white, yellow, or non-inflam- 
matory softening, and seems to be dependent on the 
brain-cells being turned into fat — the color being due 
to the fat-granules being mixed with the coloring- 
matter of the blood. In advanced cases the softened 
brain-matter is white and cream-like, and so soft that 
a weak stream of water washes it away. In the soft- 
ening due to inflammation the broken-down nervous 
substance, with the albuminous exudation and blood- 
corpuscles, causes the centre of the softening to pre- 
sent the appearance of a red pulpy mass, and hence 
the term red or inflammatory softening. 

The symptoms vary according to. the cause which 
produced them, but, generally speaking, are loss of 
intelligence and memory, affection of the speech, delu- 
sions, drowsiness, headache, and slowly advancing 
paralysis. 



SCLEROSIS. 253 



Sclerosis. 



In contradistinction to softening of the brain, it is 
convenient here to consider an affection which of late 
years has attracted considerable attention. In order to 
understand what is meant it is well to remember that 
in the nervous tissue of the brain or spinal cord there 
is another element present, which binds the cells and 
fibres together, and gives the whole substance its nor- 
mal degree of consistence. It fulfils to all intents the 
purposes of connective tissue in other organs of the 
body, and has been termed neuroglia or nerve-cement. 
In sclerosis this tissue is increased or hypertrophied, 
the proper nervous substance being in consequence 
compressed and atrophied; the result is increased 
hardness and density over a greater or less extent of 
the nervous system. Hence different names are given. 
Thus, if it involves both the brain and spinal cord it 
is called "multiple cerebro-spinal sclerosis," if brain 
alone, "multiple sclerosis" — the sclerotic or hardened 
parts in these two cases being diffused through the 
respective areas mentioned as plates or nodules of 
varying size, and to a certain extent circumscribed ; 
while in a third form affecting the brain, and termed 
"diffuse sclerosis," there are no such boundary lines, 
the hardness affecting one lobe, or even a whole hem- 
isphere. Without entering further into a subject 
which may be said to be still in its infancy, it may be 
useful for the student to recollect that diffuse sclerosis 
commences in infancy, and terminates always in im- 
becility, and often in idiocy ; multiple cerebral scle- 

22 



254 - DISEASES OF THE NERVOUS SYSTEM. 

rosis is a disease of male advanced life, with pain and 
trembling of individual or combined muscles, of arms 
and hands, or other parts, followed by paralysis, which 
ultimately extends to the trunk; in multiple cerebro- 
spinal sclerosis paralysis is noticed before trembling, 
the latter being only evidenced when a voluntary 
movement is made. 

These two latter affections were at one time de- 
scribed under their most prominent symptom, " paraly- 
sis agitans," particular attention being also drawn to 
the fact that the victims would run or plunge eagerly 
forward in a jog-trot style to any tangible object, while 
they were unable to walk slowly. This mode of pro- 
gression is now termed " festination." 

Aphasia. 

By aphasia is meant not merely loss of voice or 
aphonia, proceeding from the larynx, not merely im- 
pairment of articulation, as in the outbreak of hem- 
iplegia from paralysis of the muscles employed in 
speaking, but an impairment or loss of the intellectual, 
as distinguished from the mechanical, element of 
speech. It is an attack on that peculiar gift of man — 
articulate speech — the power by which he expresses 
his ideas, and clothes them in words. 

Although it is most frequently a combination of 
loss of power of speech, loss or impairment of the 
power of writing, and of gestures (pantomimic gestures), 
yet in its simplest form it appears to be a sudden rup- 
ture between the formation of the idea in the mind 



APHASIA. 255 

and the expression of it in words, without being neces- 
sarily accompanied by any loss of muscular power. 
Hence the division into — 1. Amnesic aphasia (forget- 
ting or confusing words); and 2. Ataxic aphasia (de- 
fective action of the muscles of articulation — inability 
to form even those words which are remembered). 

Etiology. — The cause of aphasia is obscure. It may 
occur during convalescence from fever, and is tem- 
porary, or from cerebral softening or haemorrhage, 
and is then often permanent. 

Symptoms. — The patient has an amount of words 
sometimes at his disposal, but not the right words. 
Speech is then conducted in a Malaprop fashion, or 
simply questions are answered in monosyllables, as 
by yes or no. The face is intelligent. Remembering 
faces and events, the patient is unable, either by 
writing or speaking, to find words to express ideas. 
Nouns are substituted, for nouns, verbs for verbs, 
numerals for numerals, and proper names for proper 
names. Examples are given where patients forget 
their own names, or at least are unable to express 
them. Yet an aphasic patient may be able to play 
at cards correctly, and even to read, without, how- 
ever, being able to recollect what has been read. 
Though attacks of temporary aphasia are recovered 
from perfectly, yet, if they are in any way permanent, 
the prognosis is very doubtful. 

Pathology. — Aphasia is most commonly associated 
with hemiplegia of the right side, and M. Broea has at- 
tempted to prove that this is due to the fact that the 
power of language is situated in the posterior portion 



256 DISEASES OF THE NERVOUS SYSTEM. 

of the third left frontal convolution of the brain. 
Post-mortem and clinical experience has not, however, 
borne out this idea, or shown any very definite dis- 
tinction. Ingenious theories have been founded on 
this supposition, the most practical result being, if it 
is true, that on the right side the same part has also 
latent power of language, and that we should not de- 
spair but that this may, in the course of time, be 
evoked, and a moderately intelligent life be the result. 

Treatment. — Rest, bodily and mental, is all we can 
do for an aphasic patient. All excitement should be 
avoided, the bowels attended to, and the digestion 
carefully regulated. 

Blistering or drugging seems of little avail in 
aphasia with hemiplegia. Yet if there is any syphi- 
litic history, iodide of potassium should be given (F. 5). 

Acute Meningitis. 

By this is understood acute inflammation of two 
membranes of the brain — the pia mater and the arach- 
noid. It is generally the result of injuries to the head, 
exposure to great heat, spirit-drinking, mental anx- 
iety, or retrocession of an exanthematous eruption. 

Symptoms. — Headache, vomiting, and rigors usher 
in the disease, followed by fever, flushed face, and 
red eyes, contracted pupils, and intolerance of light 
or noise. Delirium of a furious character is an early 
and pretty constant symptom. The tongue is coated, 
and the bowels are confined. If the disease is to ter- 
minate fatally, muscular twitchings ensue, sometimes 



TUBERCULAR MENINGITIS. 257 

convulsions, and the delirium merges into coma and 
collapse. 

Treatment. — Local bloodletting in the early stages, 
with an active cathartic, is useful (F. 23). The head 
should be shaved, ice applied to it, and light excluded 
from the room. Beef tea may be given at regular 
intervals. Calomel is recommended by some to be 
given every two hours until salivation is produced. 
Should mercury not be decided on, the bromide of 
potass may be ordered in large doses, with or without 
the iodide. In cases where the patient cannot swal- 
low, fluid nourishment may be administered by means 
of a tube passed through the nose. 

Tubercular Meningitis 

Is a disease not uncommon in children under five 
years. Gray tubercular granulations are found de- 
posited at the base of the brain, along the course of 
the middle meningeal artery and its branches. The 
ventricles are found distended with serum, and this 
characteristic appearance in post-mortem examina- 
tions led to its being called acute hydrocephalus, be- 
fore it was understood that the essential cause of the 
disease was the tubercles and subsequent inflamma- 
tion. The disease always terminates fatally. 

Symptoms. — Tubercular meningitis is preceded by 
signs of failing health for some weeks or months be- 
fore the attack sets in, which it does generally with 
obstinate vomiting and intense pain in the head. The 
child screams, and there is great intolerance of light 



258 DISEASES OF THE NERVOUS SYSTEM. 

and sound. The temperature varies from 101° to 
103°. This may be called the stage of excitement, 
which lasts from seven to fourteen days, and is suc- 
ceeded by a stage of depression, with a strong tendency 
to sleep. The child lies quietly on its back, and takes 
no notice of external objects. Occasionally there is 
a peculiar scream, called the " hydrocephalic cry." 
Respiration is irregular and sighing, pulse low, bowels 
constipated. This stage may last from two or three 
days to as many weeks, and is followed by a further 
stage characterized by frequent and violent convulsions, 
squinting, eyes dull and heavy, paralysis and, coma. 

Treatment — The line of treatment is indicated 
under "Tuberculosis," and is simply prophylactic. 
When the disease has become established, it seems ob- 
vious, from the nature of it, that little improvement 
can be obtained. Niemyer advocates iodide of potass, 
and Hammond advises to refrain from all leeching 
and mercurial purgatives, as only tending to make 
existence more intolerable. 

Chronic Hydrocephalus 

Can scarcely be mistaken for any other disease, as 
it consists essentially of an accumulation of fluid in 
the ventricles, or in and beneath the arachnoid. The 
head is in consequence altered in form, enlarged in 
size, the fontanelles open, the forehead prominent, and 
the face and body thin and wasted. 

In many cases it is congenital, or the result of 
chronic inflammatory disease of the membranes, ap- 



TUMORS OF BRAIN. 259 

pearing generally about the sixth month, and lasting 
for a varying term of months or years, with a fatal 
termination either from exhaustion or coma. 

Treatment. — Compression, by means of adhesive 
plaster applied over the whole cranium, seems service- 
able ; and if that fails, puncturing and drawing off 
the fluid may be tried. Cases have been recorded 
where mercury was beneficial, followed by iron. Any 
tendency to this disease should be met by fresh air, 
regulated strengthening diet, and cod-liver oil. All 
attempts to exercise the brain should be discouraged. 

Encephalitis 

Is a local inflammation often followed by abscess. 
The part most frequently involved is the gray matter 
of the cerebrum or cerebellum, and the size of the af- 
fected part varies from that of a walnut to that of the 
closed fist. It is caused by injuries, or from extension 
of inflammation from the ear, and is said always to 
terminate in death. 

The symptoms during life are increase and after- 
wards decrease of the sensibility, with headache, con- 
vulsions, paralysis, or coma. 

Tumors of Brain 

May be of various kinds, vascular, parasitic, can- 
cerous, tubercular, or syphilitic, etc , etc. 

The growth of a tumor is at the expense of the 
brain, which in health nearly fills the cranial cavity ; 
hence pain, usually fixed and severe, is in the majority 



260 DISEASES OF THE NERVOUS SYSTEM. 

of cases a prominent symptom, with disordered sight, 
hearing, and taste. Convulsions, local paralysis, and 
giddiness are frequent concomitants. If the pain in 
the head is severe, fixed, and intense, and there is also 
a history of syphilis, there is every probabilty of the 
tumor being of syphilitic origin, and this is strength- 
ened by finding nodes on the surface of the body. 

Paralysis. 

Paralysis or palsy denotes loss of motor power and 
sensibility in one or more parts of the body. The loss 
of motor power in the parts affected, the most striking 
characteristic, may vary from the slightest feebleness 
to the most complete inability of movement. The 
former, the incomplete, is now often termed " paresis," 
while " paralysis" is reserved for the complete or 
nearly complete. Paralysis may be general or partial, 
as the whole or only a part of the body is affected, and 
various names indicate when the paralysis is only par- 
tial. Thus when it is limited to one side it is termed 
" hemiplegia ; " if confined to the lower half of the 
body, "paraplegia;" if only affecting a small portion 
of the body, as face, foot, or leg, it is designated " local 
paralysis ; " and if the nerve specially implicated in 
causing this is 'known, it can be fitly designated accord- 
ingly, e. g., " facial paralysis," " paralysis motor oculi." 
Again, paralysis may be due to certain occupations, 
hence the names " mercurial paralysis," " lead paraly- 
sis;" or if associated with certain symptoms, it is 
known by these, hence " wasting paralysis," " paraly- 
sis agitans." 



PARALYSIS 261 

The more prominent of these affections will now be 
briefly considered. 

General Paralysis. — In the course of some 
forms of mental derangement a gradually advancing 
paralysis sooner or later involves nearly every mus- 
cle of the body, and hence it has been called " general 
paralysis." Paralysis of the lips and tongue leads to 
defective, blurred articulation, and the invasion also 
of the facial muscles gives the face a sad or blank 
look. As the disease progresses to its almost invari- 
ably fatal termination, the physical powers diminish, 
and the patient, unable to walk, stand, or sit, is con- 
fined to bed for the rest of his existence; death occur- 
ring; either from difficult deglutition, leading to chok- 
ing, or from sheer exhaustion, or other intercurrent 
affection. Atrophy of the optic nerve can often be 
detected by the ophthalmoscope. 

Hemiplegia. — This is generally spoken of as a 
paralytic stroke, and though it may be associated with 
many of the affections previously mentioned, it is 
most commonly due to cerebral haemorrhage. As the 
result of this or of some of the other cerebral diseases, 
the left side of the body is most commonly found 
paralyzed, although the actual seat of the lesion in 
the brain is on the right side in the great majority of 
cases. The decussation of the pyramids accounts for 
this phenomenon. Owing to the affection of the facial 
nerve, the cheek hangs loosely, with the angle of the 
mouth slightly drawn upwards to the sound side, and 
the tip of the tongue, when protruded, by the implica- 
tion of the hypoglossal, is pushed to the sound side, 
owing to the counterbalancing power of the corre- 



262 DISEASES OF THE NERVOUS SYSTEM. 

sponding muscles being lost. The articulation is im- 
perfect, and if the third nerve is also involved, the 
upper eyelid drops, the pupil is dilated, and there is 
a divergent squint. The loss of motion may be com- 
plete in the arm and leg, and the patient lies in bed 
helpless. If it is partial, or if the original attack is 
being recovered from, the gait is peculiar, the affected 
leg being drawn after the sound one in a shuffling way, 
with, if the patient is able to lift the foot so far, the 
toes pointed -to the ground. In most cases there is 
loss of sensibility as well as motion. 

Hemiplegia may be permanent, or it may tend to 
recovery, which commences in the leg. 

Treatment — Two weeks after the original seizure, 
but not sooner, it is by some recommended daily to 
use friction over the paralyzed parts, with flexion and 
extension of the joints. Subsequently the subcutane- 
ous injection of strychnia is recommended, or prepara- 
tions of phosphorus (F. 85) may be taken internally. 
The most valuable agent is, however, the application 
of the constant current. 

Paraplegia has usually an insidious commence- 
ment; the feet and legs feeling weak, cold, or ting- 
ling. As the disease advances, the weakness increases, 
sensibility and power of motion are gone, and the 
patient is obliged to remain in a horizontal position, 
having lost also control over the bladder and rectum. 
Rest is frequently disturbed by involuntary move- 
ments of the limbs. 

Paraplegia may be due to caries of the vertebrae, to 
concussion or compression, congestion, inflammation, 



PARALYSIS. 263 

or softening of the spinal cord or its membranes. It 
may also accompany other affections, as hysteria, preg- 
nancy, worms, or urinary diseases. The history must 
be the chief guide to the diagnosis as to whether the 
paraplegia is primary or secondary, dependent on con- 
gestion or diminished nutrition. 

Treatment. — If from the nature of the symptoms it 
is considered that congestion, or too much blood being 
sent to the cord, originates the paraplegia, it is desira- 
ble to administer the ergot of rye internally, and bella- 
donna externally. Both these remedies contract the 
vessels of the cord and membranes. If, on the other 
hand, there are evidences of malnutrition or of reflex 
paraplegia, strychnia is to be preferred, combined, if 
there is much restlessness, with opium and a generous 
diet. In addition to this, if the paraplegia seems of 
reflex origin, the cause should, if possible, be removed. 
Thus worms must be expelled, the bladder relieved, 
and hysteria obviated. 

Facial Paralysis, or Bellas Paealysis, is an 
affection of the portio dura or facial portion of the 
seventh pair of nerves, either at its origin or in its 
course, or as the result of pressure. The appearances 
are characteristic, as there is paralysis of motion, more 
or less complete, of the muscles supplied by the nerve. 
Hence the face has a blank unmeaning expression. 
The eye of the side affected cannot be closed, tears run 
over the cheek, the mouth cannot be pursed up to 
whistle, nor expanded to smile. In accordance with 
the anatomy of the facial nerve, it will be found that 
if the morbid process originates above the origin of 



264 DISEASES OF THE NERVOUS SYSTEM. 

the chorda tympani nerve, there will be a diminution 
of the sense of taste in the corresponding side of the 
tongue; if behind the gangliform enlargement of the 
petrosal nerves, there will be, in addition to the other 
symptoms, paralysis of the parts supplied by these — 
the uvula will be drawn to the sound side, and the 
palatine arch will fall down and become straight in- 
stead of curved. 

By the tongue being unparalyzed and deglutition 
unimpaired it is distinguished from glosso-labial pa- 
ralysis, and by the fact that the patient cannot close 
the eye, from the facial paralysis of hemiplegia. 
Facial paralysis is often the result of cold or debility 
or syphilis, and tends to recovery in from six to ten 
weeks. If dependent on cerebral or intracranial lesion, 
the prospect of cure is remote. 

Treatment — The persistent use of electricity is of 
great importance, one pole of the induced current 
being placed over the point of exit of the nerve, while 
the other is applied in succession over the various 
muscles supplied by it. The healthy nutrition of the 
system should be secured by hygiene and tonics, es- 
pecially strychnia. If there is reason to suspect a 
syphilitic taint, give potash and mercury (F. 1). 

Paralysis of the Third Nerve, Motor Oculi. 
— The paralysis of this nerve depends upon tumors 
or exudations pressing on it, or cold, or reflex irrita- 
tion, such as worms or indigestible food. The upper 
eyelid in consequence falls down, occasioning the con- 
dition termed ptosis, and if of intracranial origin the 
eyeball is turned outward and the pupil is dilated. 



PARALYSIS. 265 

If due to cold and not dependent on cerebral causes, 
recovery is the rule. 

Glosso-labio-laryngeal Paralysis. — The es- 
sential lesion here is found in the medulla oblongata 
and upper part of the spinal cord, and consists of 
atrophy of nerve-cells connected with the origin of the 
hypoglossal, spinal accessory, and pneumogastric 
nerves. As 'a consequence there is a slow yet steady 
loss of power of the muscles of the tongue, soft palate, 
pharynx, and larynx, and also of the orbicularis. 
The disease, dependent on unknown causes, invariably 
results in death from asphyxia or cessation of the 
heart's action through implication of the cells of the 
pneumogastric. 

Mercurial Palsy or Tremor is caused by long- 
continued exposure to the fumes of mercury, and is 
characterized by tremors and jerkings of the voluntary 
muscles, beginning in the arms, but extending some- 
times to the legs, tongue, and jaws. These move- 
ments are increased by the mind being brought to 
bear upon them or by attempts at exertion. 

Permanent bad health is often the result. 

Treatment. — This consists in withdrawal from the 
cause to a fresh, pure atmosphere, and giving iodide 
of potassium. 

Lead Paralysis has been considered under 
" Colic," page 176. 

Wasting Palsy, Progressive Muscular Atro- 
phy. — In this peculiar disease loss of strength in cer- 
tain muscles of the body, particularly the shoulder, 
arms, and hands, attracts first the patient's attention, 



266 DISEASES OF THE NEKVOUS SYSTEM. 

and this is followed by atrophy of the muscular tissue, 
not merely of the parts primarily affected, but pro- 
gressing until every voluntary muscle of the body 
may be involved, with the exception of the muscles of 
the eyeball or the levator palpebrse superioris. The 
affection seems peculiar to males from twenty-five to 
thirty-five years, and in some instances to be hered- 
itary. The cells of the anterior tract of* gray matter 
of the spinal cord appear to be destroyed by a slow 
chronic inflammation; and the presumption is, since 
the disease is unaccompanied by paralysis, that the 
cells involved are not motor cells, but those which are 
supposed to govern the nutrition of muscles — trophic 
cells. The prognosis is very unfavorable, especially 
if the disease is hereditary. 

Treatment. — This must be based on the steady em- 
ployment of the continuous and interrupted currents, 
with tonics or iodide of potassium if there is any sus- 
picion of syphilis. 

Writer's Cramp is a form of nervous disorder at- 
tacking those who are engaged in writing a great 
deal. It is first attended with fatigue and inability 
to hold the pen firmly, and ultimalely, if it progresses, 
by spasmodic irregular movements of the fingers and 
thumb when any attempt at writing is made. 

Half-measures are of little avail in writer's cramp, 
and complete abstinence from work is necessary to 
restore nervous vigor. 

Infantile Spinal Paralysis is generally ushered 
in with fever, convulsions, and pain in the back, 
marking the seat of the disease as being in the spinal 



NEURALGIA. 267 

cord. Then it is noticed that the child does not use 
one hand or kick with one leg, or the paralysis ob- 
served may be restricted to a group of muscles, or em- 
brace the four limbs. The temperature of the affected 
limbs is lower than the corresponding sound ones. 
This loss of power may last a month or six months, 
and is succeeded by atrophy, with loss of the electric 
contractility of the affected muscles, and in some cases 
even by arrest of development and degeneration of 
the bones. The essential lesion appears to be situated 
in the anterior horns of gray matter, consisting of an 
inflammatory softening leading to degeneration and 
atrophy of the part affected. 

Treatment. — This is local and general. The induced 
current should be applied directly to the skin over the 
paralyzed muscles, and afterwards friction with a dry 
towel or flesh-brush should be practiced several times 
in the course of a day. Ergot should also be given 
in ten-drop doses of the fluid extract thrice daily, and 
may be increased up to half a drachm. If the stage 
of atrophy is reached, ergot is useless, and strychnia 
must be administered (F. 80), with the persevering 
use of the induced current, should the muscular con- 
tractility still continue. "If this is lost to the in- 
duced current, the cure will be difficult and the treat- 
ment protracted; if the primary current is also power- 
less, a cure is impossible." (Hammond.) 

Neuralgia. 

Under this head should be included affections which, 
so far as can be ascertained, are not due to diseases of 



268 DISEASES OF THE NERVOUS SYSTEM. 

the brain or spinal cord, but the seat of which is in 
the nerves themselves. 

Different names are given, according to the site or 
the nerves affected. Thus we have facial neuralgia, 
or tic douloureux, sciatica, and lumbago. 

Facial Neuralgia is more apt to attack females 
than males during adult life, and seems often to have 
some connection with menstruation, lactation, mental 
excitement, or exposure to cold. The pain is fre- 
quently excruciating, coming on and disappearing at 
fixed hours of the day. It may attack the nerve at 
any or all of its divisions. 

Sciatica. — The pain is referred to the course of 
the sciatic nerve or its branches, and may be restricted 
to the gluteal region or upper part of the thigh, or it 
may extend to the soles of the feet. It generally 
lasts from two to three months, but is apt to recur. 
It is often associated with a lowered physical stamina, 
and sometimes there is a previous history of gout, 
rheumatism, or syphilis. 

Lumbago and Pleurodynia. — The dorsal and 
intercostal nerves are here the seat of pain, which is 
continuous in character and much increased by exer- 
tion. The mere act of straightening the back in lum- 
bago often causes great agony. 

Treatment — In facial neuralgia quinine and arsenic 
are efficacious, with the addition of colchicum if there 
is a history of gout, or liquor potass if rheumatism. 
Locally, to arrest the paroxysms, morphia may be sub- 
cutaneously injected. A fresh pure air is indispens- 



EPILEPSY. 269 

able to any treatment. Cod-liver oil, iron, and 
strychnia are often useful (F. 4, 75, 78). 

In sciatica one injection or two daily of morphia 
into the tissue of the nerve, or as near to it as possi- 
ble, seems not only palliative, but even curative. 
Among other remedies which may be mentioned, 
stand strychnia, phosphorus, and iron, acupuncture, 
repeated blisters, Turkish baths, or the local applica- 
tion of aconite and veratria in the form of an oint- 
ment. The induced current, continued for half an 
hour, is sometimes singularly beneficial in this as in 
the other forms of neuralgia (F. 63). 

Epilepsy, 

Sometimes also termed falling sickness, and popu- 
larly, fits. 

No definition can be given of epilepsy, because no 
definition would embrace all its phenomena. Yet it 
may be stated generally to be a disease characterized 
by certain leading features, viz., sudden loss of con- 
sciousness and sensation, with clonic spasms of the 
voluntary muscles, usually followed by exhaustion and 
coma. The essential element of epileptic paroxysms 
is loss of consciousness. 

Etiology. — The tendency to epilepsy is often hered- 
itary, but various other causes may be mentioned. 
Occurring often at puberty, it is justly considered in 
many cases to be a lamentable corollary of masturba- 
tion, of too early and frequent sexual intercourse, of 
malformations of the head, of the scrofulous diathesis, 

23 



270 DISEASES OF THE NERVOUS SYSTEM. 

or it may be the direct result, either to himself or 
children, of a habitual drunkard's habits. 

These are centric causes ; while as eccentric sympa- 
thetic causes may be mentioned, uterine derangements, 
irritation of teething, and a disordered state of the 
stomach and intestines. Fright is a prominent excit- 
ing cause in a person predisposed to epilepsy. The 
first seizure occurs usually betwixt the tenth and 
twentieth year. 

Symptoms. — These are best divided into what occurs 
before, during, and after a fit. 

Warnings of various kinds may precede the attack. 
Spectral illusions, confusions of thought or speech, 
headache, dimness of vision, or what the patient de- 
scribes as the indescribable sensation of an inward 
working. The most curious forerunner of a fit is what 
is termed the " epileptic aura or vapor." It seems to 
come from some distant part of the body, and patients 
describe it creeping along, as water may trickle or a 
serpent crawl, until it reaches the head or stomach, 
when consciousness is lost in the fit; or there may be 
what is termed a "motor aura" in contradistinction 
to this, the sensory aura, recognized by twitching or 
palsy of some part of the body. 

With or without these precursors the fit is ushered 
in by a shrill cry, and the patient falls down uncon- 
scious, and struggles hard in convulsions. Unable to 
select a convenient place, the fall in itself may seriously 
hurt him. The patient gnashes his teeth, pushes out 
and often bites his tongue, foam gathers at the mouth, 
forehead and eyebrows twitch, eyes are partly open 



EPILEPSY. 271 

and partly shut, and the pupils are insensible to light, 
and dilated. 

The body writhes in convulsions, or is jerked from 
side to side, and what is popularly thought to be 
characteristic of the disease may be observed, viz., 
"the flexing of the fingers, and more especially the 
flexing of the thumb into the palm of the hand." The 
urine and feces are often passed involuntarily. The 
fierceness and alarming nature of the attack renders 
minutes hours to the bystanders, as a fit averages 
only five to eight minutes in its duration, although it 
may last half an hour or more. 

After perhaps a more sharp convulsive movement, 
there is deep sleep, from which the patient awakens 
with utter unconsciousness of what had occurred; with 
headache, red eyes, dilated pupils, and a peculiar 
stupid expression of countenance. This is succeeded 
by seemingly restored health, but ultimately by other 
seizures, the interval between the occurrence of which 
varies. Usually an interval of four or five weeks 
elapses, and this is followed by a series of fits, occur- 
ring at short intervals. Although epileptic attacks 
are not primarily fatal, yet gradually the constitution 
is sapped, the mental and bodily vigor impaired, and 
not unfrequently the unhappy victim of epilepsy ends 
his days in an asylum. Such is a description of what 
is termed the "grand mal," and from which a sliding 
scale can be traced to what is known as the "petit 
mal." Here unconsciousness may be as complete as 
in the severer forms, but the fits may last only a 
second or two, as, for instance, the person stopping in 



272 DISEASES OP THE NERVOUS SYSTEM. 

the middle of a conversation for a few moments, to re- 
sume talking where he left off, quite unconscious of 
the fit. 

Pathology. — Should death occur during a paroxysm, 
the brain is found more or less congested, while, in 
long-standing cases, it may be softened or indurated, 
and increased in weight. The researches of Schroeder 
van der Kolk point to the medulla oblongata as the 
seat of the disease, which is supposed to be more ex- 
citable and sensible, by an increased afflux of arterial 
blood, or from the accumulation in the system of some 
materies morbi^ which leads to an explosion as seen by 
the epileptic fit. Hughlings Jackson and Ferrier 
have given rise to epileptiform fits in animals by 
stimulating (galvanic) certain convolutions of the 
brain, which if removed do not cause paralysis, but 
yet when stimulated give rise to these convulsions. 
Hence, epilepsy seems to have an explosive lesion, 
like the discharge of a battery, although we cannot 
say that an excess of energy is manifested, for we must 
take into account the energy required for constraint, 
which is taken away, and thus all energy is concen- 
trated in the abnormal convulsion. 

Treatment — This consists of two points : 

1st. What to do during, and 2d, after a fit. 

1. Chloroform may stop a fit, but it leaves the per- 
son more stupid and afflicted afterwards, and is thus 
inadvisable. Certain obvious duties are necessary. 
If the head is hot, apply wet cloths, if feet cold, warmth. 
The necktie should be unloosened, and the patient 
placed in such a way, with head somewhat elevated, 



EPILEPSY. 273 

as to prevent him doing himself injury against articles 
of furniture. If possible a piece of wood, cork, or 
india-rubber should be placed between the teeth to 
prevent the tongue being bitten. 

2. It is impossible to get rid of certain predisposi- 
tions, such as a strumous diathesis, a misshapen head, 
or organic lesion of the brain or spinal cord. At the 
same time some eccentric causes are remediable. If 
due to worms, give a vermifuge. If a syphilitic history 
is told, iodide of potass and the bichloride of mercury 
are serviceable. If dependent on vicious habits, the 
patient must be warned against these." The system 
should also be braced up by good air, cheerful society, 
and the shower-bath, if it produces after using it a 
genial glow of warmth. 

With regard to other remedies, the following are the 
most noteworthy. Counter-irritation to the nape of 
the neck, either by cupping, leeching, setons, or blisters. 
Atropia, gr. ij ; spt. vin. rect., 5ij. Begin with one 
drop and increase to 20 daily, continuing this for 
months, and gradually diminishing the dose. Nitrate 
of silver and acetate of zinc have also been recom- 
mended. 

Latterly the favorite and most useful drug seems 
to be bromide of potassium, given in 10, 20, or 30 
grains thrice daily, and continued for some time. 

Numerous other supposed specifics might be men- 
tioned, the fact being, as Esquirol remarks, " that 
epileptics are apt to improve for a time under every 
new form of treatment.'' 

Careful watching is important in epilepsy, so that 



274 DISEASES OF THE NERVOUS SYSTEM. 

patients may not be in a dangerous position when a fit 
occurs. 

Chorea 

Literally means a dancing or jumping, being de- 
rived from the Greek word yopzia. It is the " Saint 
"Vitus's dance " of this country, the "St. Weit" of 
Germany, and "St. Guy" of France. It may be 
defined as a disease most commonly affecting girls 
between the sixth and the sixteenth years, and char- 
acterized by irregular action and restlessness of the 
voluntary muscles of the face and limbs. It some- 
times attacks boys. As a rule it is confined, in either 
sex, to the left side. 

Etiology. — The exciting cause is usually fright, by 
which the stability of the nervous system is disturbed. 
Sometimes it is due to worms and to carious teeth; 
and, as it is often associated with a previous history 
of rheumatism, and with a systolic murmur at the 
apex of the heart, it is by many considered due to this 
disease, or to embolism in some part of the cerebral 
circulation. The general health is usually below par 
at the time of the attack. 

Symptoms. — Twitching of the muscles of the face is 
generally first observed. This is followed by a halt- 
ing or unsteady movement of the leg, which the patient 
drags. Then the hand of the same side is affected, 
and the patient is unable to keep it in the same posi- 
tion for any length of time. It is jerked away from 
any position in which it is placed, and it is unable to 
retain anything within its grasp. Patient has power, 



CHOREA. 275 

but not control. The articulation is impeded, and in 
severe cases the tongue, when protruded, is drawn back 
again with a sudden snap; but consciousness is not 
affected. Looking at, or drawing attention to, the 
patient increases the irregular movements. It may 
be unilateral or bilateral, — in the former case being 
called hemichorea. During sleep the movements 
usually cease. 

The duration of the disease may be stated to be 
from five to six weeks, although it sometimes becomes 
chronic and lasts several months. The disease seldom 
terminates fatally, except when, as rarely happens, it 
is very acute, and complicated with other affections, 
as cholera or acute rheumatism. In such cases it is 
attended with fever, the spasms being of excessive in- 
tensity; not painful, but still prohibiting sleep, and 
thus exhausting the system. 

Pathology. — The post-mortem appearances in those 
cases which do prove fetal give little insight into the 
nature of the malady. In some the brain seemed per- 
fectly healthy, in others there has been noted a serious 
effusion beneath the arachnoid and into the ventricles. 
In one case, related by Dr. Aitken, the specific gravity 
of the corpus striatum of the right side was increased. 

Treatment. — After a brisk cathartic, combined, if 
there is any suspicion of worms, with an anthelmintic, 
the patient should have a carefully regulated easily 
digested diet; and, if unable to feed herself, should 
be assisted to do so. 

Various remedies have been recommended, a^ steel, 
oxide of zinc, sulphate of copper, nitrate of silver, 



276 DISEASES OF THE NERVOUS SYSTEM. 

bromide of potass, and chloral. None of these has 
been in my hands nearly as useful as arsenic, given 
in the form of liq. arsenicalis thrice daily. 

Sometimes I have combined the arsenic with iron, 
as in the following formula: 

R. Vin. Ferri, gij. 

Liq, Arsen., rr^v. 

Ft. haust. — To be taken thriee daily. 

In the very acute cases, where a fatal issue may be 
feared from sheer exhaustion, it would be proper to 
keep the patient under the influence of chloroform for 
protracted periods. 

It may here not be inappropriate to state that a 
peculiar affection of the nervous system, characterized 
by inability to retain the fingers and toes in any posi- 
tion in which they may be placed, and by their con- 
tinual motion, has been termed by Hammond athetosis 
(aOero<:, without fixed position). The conditions which 
occasion it are as yet unknown. It seems, however, 
to resist all therapeutic efforts. 

Delirium Tremens 

May be defined as alcoholic poisoning, attended 
with a delirium in which there are great restlessness, 
suspicion, trembling, and various delusions. 

Etiology.— The cause is drink. Distilled spirits 
more surely than wine; wine than beer. The man, it 
may be added, who, with a highly- wrought nervous 
organism, drinks to excess to drown the consciousness 
that he is drinking, is more likely to be affected, with 



DELIRIUM TREMENS. 277 

delirium than the habitual swiller, who may drink to 
excess, but is able to sleep it off'. 

Symjrtoms. — Sleeplessness is the most characteristic 
symptom, and this sleeplessness is associated with 
busy restlessness, a chattering tongue, fidgety hands, 
and imaginary spectra. The tongue is protruded in 
a tremulous way, as in fever, but it is not brown and 
parched, but moist and creamy. The pulse is soft and 
compressible; the skin often bathed in perspiration. 

The patient may coherently reply to a question or 
two, but soon after relapses into the fancies character- 
istic of the disease. These fancies are not pleasant, 
but associated with the low r est and most repulsive 
forms. Thus rats, mice, serpents, and imaginary de- 
mons are crawling about him, and, in endeavoring to 
escape or destroy these, his mind is sorely tried. Often 
he peeps suspiciously behind the curtain, draws the 
bedclothes over him, or attempts to leave his bed. 
Cowardice rather than violence is exhibited both with 
regard to himself and his actions towards others. 

The disease tends to recovery, on the third or fourth 
day, by a sleep from which the patient awakes re- 
freshed. In fatal cases the symptoms are aggravated, 
and attended with intense watchfulness, low 7 mutter- 
ing delirium, subsultus tendinum, and great exhaus- 
tion. 

Pathology. — In fatal cases the subarachnoid tissue 
has been found so infiltrated with fluid as to raise the 
arachnoid to the level of the convolutions. The cere- 
bral arachnoid exhibited considerable opacity all over 
the hemisphere, and the ventricles contained a small 

24 



278 DISEASES OF THE NERVOUS SYSTEM. 

amount of fluid; while the cerebral arteries and other 
parts of the brain were perfectly healthy. 

Treatment. — The objects in treatment are, to prevent 
the further introduction of the poison into the system, 
to quiet the nervous excitement, and to sustain the 
strength while the accumulation of alcohol is being 
thus eliminated from the system. 

To fulfil these indications all stimulants should be 
forbidden if the patient is young and strong. If there 
is a history of previous attacks, and the patient is 
weak, it is advisable to taper off their withdrawal. 

If the patient can be persuaded to take some beef 
tea; or chicken soup, there is not much danger in the 
disease nor necessity for medicinal treatment. If, as 
often happens, there is loathing of food, it seems ad- 
visable to place six grains of calomel on the back of 
the tongue. The liver is thus stimulated to action. 
Opium must also be given afterwards, combined with 
antimonial wine, or, if the stomach cannot retain these, 
morphia must be injected hypodermically until sleep 
is induced. If the pupils are contracted under its 
use without sleep, it has been pushed far enough and 
should not be continued. Bromide of potass and 
chloral are sometimes substituted for opium benefi- 
cially. Nourishment as indicated should be given 
often and cautiously (F. 69, 70). 

All force, as in the form of strait-jackets, should be 
discountenanced. The services of well-skilled attend- 
ants, combined with kindness and humoring of the 
fancies, seem to be sufficient, even in the most violent 
cases. It is well not to restrict the patient from 



SUNSTROKE — HYSTERIA. 279 

reasonable muscular exercise, as this conduces to sleep 
and appetite. 

Sunstroke. 

Coup de soleil and heat apoplexy are synonyms ap- 
plied to a disease peculiar to warm climates, but oc- 
curring also in this country. Two forms are observed, 
one in which the disease is due to the direct influence 
of the sun's rays, the person being struck down sud- 
denly, with stertorous breathing, slow, full pulse, un- 
consciousness, and marked heat of head. In the other 
form excessive heat without exposure to the sun may 
produce, by some blood-change, phenomena similar 
to syncope, with weak pulse, and no stertor of the 
breathing. 

Nothing characteristic is detected after death in the 
brain. 

Treatment. — Apply ice or iced water freely to the 
head, which should be raised. Afterwards leech or 
cup behind the ears, and administer a purgative enema 
for the first form, the true coup de soleil. For the 
second, cool the body by means of cold douches, after- 
wards apply sinapisms to the spine, epigastrium, and 
limbs; administer also stimulants. 

Hysteria. 

Hysteria is best known by its clinical history, as 
evidenced by its affecting the mind, the sensibility, 
motor or visceral action, or as it counterfeits other 
disorders. 



280 DISEASES OF THE NERVOUS SYSTEM. 

Mental Symptoms. — These may be of the most 
varied character. 

There may be extreme talkativeness or utter silence ; 
depression of spirits to the shedding of tears succeeded 
by immoderate laughter, from one and the same cause. 
Emotions exactly opposite to the proper ones for the 
occasion may be excited. A tale of grief directly af- 
fecting the patient may be greeted with every sem- 
blance of joy. Good fortune may awaken a wringing 
of the hands, and a shedding of tears. The news that 
burglars have entered the house may induce stoical 
indifference. 

Illusions are common, — a ball rolling over the floor 
is mistaken for a rat; rain on the roof for burglars 
entering the room. 

Hallucinations are equally frequent. 

" One patient sees angels, another demons, another 
animals of various kinds." 

That these disordered mental emotions, illusions, 
hallucinations, and other allied phenomena, are not 
due to insanity, is evidenced by the fact that they do 
not last long, nor color much the conduct of life. 

Sensibility may be increased or diminished. 

Pain is felt in varying situations, rarely fixed to 
one place, and generally described as excessively 
acute. Pain in the joints, especially the knee, is a 
common hysterical affection ; though this may be 
accompanied with swelling, there is no accumulation 
of fluid in the synovial membrane. The pain in this, 
as in other parts, also ceases at night; is increased by 
handling rather than by a severe pressure ; and may be 



HYSTERIA. 281 

cured spontaneously by prayer, by sudden movements, 
or other causes. 

The organs of the special senses may be sensibly 
exalted, vision more keen, hearing more acute, and 
smell morbidly sensitive. 

Anaesthesia, though not so common as hyperesthesia, 
may yet be a phenomenon of hysteria. Its most com- 
mon seat is the skin, and to such an extent may this 
be the case that no irritation of the particular part 
affected is of any avail, not even the wire-twist of the 
electric coil. It is to be noted that the attacks are not 
preceded or accompanied by numbness. 

Alterations of motion, as evinced by paralysis, or 
clonic or tonic spasm. Thus there may be loss of 
voice, suddenly appearing and disappearing, or partial 
or complete paraplegia. 

Spasm, fixed (tonic), frequently affects the pharynx, 
giving rise to the sensation of a ball in the throat, 
" globus hystericus." 

Spasms (clonic), simulating chorea and epilepsy, are 
the frequent outcome of attendance on spiritualistic 
or revival meetings. 

Digestive Symptoms are various and not uncommon ; 
the urine is usually increased in quantity, of a low 
specific gravity and light color. It is frequently 
voided unconsciously during a paroxysm. 

Causes. — The affection is peculiar to females, espe- 
cially between the ages of sixteen and twenty-five. 
Above all causes may be mentioned lack of aim in 
life, thus throwing the mind and the emotions back 
upon self. Hysteria is unknown in savage countries, 



282 DISEASES OF THE NERVOUS SYSTEM. 

and it seems to be a direct attendant frequently of 
luxurious habits and perhaps ungratified desires. It 
is frequently met with in patients suffering from 
uterine or menstrual affections. 

It is often hereditary. 

Morbid anatomy and pathology contribute nothing 
to elucidate the mystery of hysteria. Brain, spinal 
cord, and sympathetic nerve give no evidence of its 
former presence ; neither do the generative organs, the 
stomach or intestines. It seems essentially to consist 
in the predominance of the emotions over the intellect, 
and especially over the will; the intensified character 
of this interfering with the sensibility of various parts 
of the body, and sometimes deranging the contractility 
of the muscles. 

Treatment, — Gain the confidence of the patient, and 
thus treatment, medicinal, moral, or dietetic, will be 
more apt to produce the desired effect. During the 
paroxysms nothing equals chloroform, though some- 
times dashing water on the face and moral suasion 
may be sufficient. 

During the period between the paroxysms the treat- 
ment must be mainly directed against symptoms, If 
hyperesthesia, a full course of bromides is essential; 
if anaesthesia, the induced current over the affected 
region. 

For hysterical paralysis, strychnia and phosphorus, 
together with the use of electricity both of the primary 
and induced forms, should be tried. In hysterical 
vomiting, bismuth or hydrocyanic acid (F. 9). 



DISEASES OF THE SPINAL CORD. 283 

Finally, valerian, or valerianate of zinc, is a favor- 
ite remedy; and careful attention to any menstrual 
disorder is necessary, should such exist (F. 14). 



DISEASES OF THE SPINAL CORD. 

Spinal Meningitis. — Inflammation of the mem- 
branes of the cord may be either acute or chronic. It 
is generally caused by exposure to cold or moisture, 
or injuries. 

It is characterized in both forms by pain in the 
back, which is increased by movement, and follows 
the course of the nerves proceeding from the diseased 
region ; by spasms in the muscles of the back, reflex 
motion unaffected, and paralysis, varying in extent 
and intensity, but generally progressive to a fatal 
termination. 

Pathology. — The lesions found after death are gen- 
erally restricted to the pia mater and subarachnoid 
space, and consist in thickening of the membrane, 
turgid ity of the vessels, and the effusion of a large 
quantity of spinal fluid. 

Myelitis. — Inflammation of the spinal cord may 
either be general, affecting the whole extent of the 
cord, or partial, restricted to a limited portion. It is 
more frequently the result of an injury than anything 
else. The symptoms vary with the seat of the dis- 



284 DISEASES OP THE SPINAL CORD. 

ease. The most prominent, however, are pain in the 
back, a feeling as of a tight cord tied round the body, 
rapid and complete paralysis, alkaline urine, a marked 
tendency to sloughing of the skin, speedy loss of elec- 
tric contractility, and depression of temperature in the 
paralyzed parts. 

The termination of acute general myelitis is in 
death, sooner or later. In the partial variety life may 
be prolonged, but at the expense of loss of motion and 
sensibility below the diseased portions. 

Hemorrhages into Spinal, Cord. — Extravasa- 
tion of blood may occur into and around the cord 
through disease of the vessels with increased blood- 
pressure. It is characterized by a sudden onset, local 
pain, reflex and motor paralysis of varying amount, 
and occasional jerkings of the muscles. The bladder 
and rectum are frequently paralyzed. Recovery often 
occurs if the haemorrhage is not very extensive. 

Congestion. — As the result of cold or over-exer- 
tion, congestion of the spinal cord may ensue, the 
chief symptoms of which are some pain in the spine, 
with tingling of the extremities, and paraplegia, which 
is, however, rarely complete. Paralysis of the bladder, 
with constipation, is common, but there is no tendency 
to sloughing or wasting of the muscles. The result is 
sometimes recovery, sometimes permanent paraplegia. 

Softening of the Cord is the common termina- 
tion of acute myelitis, but it may originate primarily, 



DISEASES OF THE SPINAL CORD. 285 

without any evidence of inflammation, hence it has 
been termed " non-inflammatory softening." The first 
symptom observed is numbness of those parts of the 
body below the seat of lesion ; this is followed by 
want of motor power, and the two advancing together 
afterwards become more and more marked. The dis- 
ease progresses to utter helplessness. The functions 
of the bladder and bowels are interfered with, and 
there is a marked tendency to sloughing of the skin. . 
The nerve-cells in the gray substance are destroyed, 
and the nerve-tubules of the white substance have 
their place taken by oil-globules and granule- masses, 
the constituents of which are fat. 

Spinal, Irritation. — The term spinal irritation 
seems first to have been used by Dr. C. Brown of 
Glasgow, in 1828. Its existence as a distinct disease 
has given rise to much controversy. Hammond, while 
retaining the term, thinks that it is due to anaemia 
of the posterior columns. It is specially recognized 
by the occurrence of tender spots in the skin or deeper 
tissues over one or more parts of the spine, and by 
neuralgic pains shooting over different regions of the 
back. It is peculiar to females of a weak habit of 
body between the ages of fifteen and twenty-five. " In 
general terms, it may be stated that any cause capable 
of reducing the system may produce spinal irritation." 
In doubtful cases, where it may be confounded with 
myelitis, meningitis, or congestion, it is said that a 
hypodermic injection of one-thirtieth of a grain of 
strychnia will settle the difference. This invariably 



286 DISEASES OF THE SPINAL CORD. 

aggravates the symptoms of the other diseases, while 
it is the efficient means of cure in spinal irritation. 

Locomotor Ataxy 

Is a peculiar form of paralysis, due to disturbed co- 
ordination of muscular movements. In health the 
muscles must contract and relax together, in unison 
with the movements we may desire. If one muscle 
contracts too soon, and another relaxes too quickly, 
then there is disturbed co-ordination of muscular 
movements. 

Etiology. — The cause of locomotor ataxy is obscure, 
yet undue exposure to cold or damp after a long 
journey, venereal excesses, mental exhaustion, and 
syphilis, seem in some cases to lead to its occurrence. 

Symptoms. — The origin is insidious. The first sus- 
picion of there being anything wrong is frequently 
awakened by an inability to run, through a feeling of 
the legs being too heavy. This is followed by fatigue 
after any exertion, and by increased micturition. 
The desire for sexual intercourse is at this stage of the 
disease increased. The disease progresses often slowly, 
and months and years may intervene before the patient 
presents the well-marked symptoms of locomotor ataxy, 
viz., a straddling gait in movement, the foot being 
lifted high in the air and planted down heel first. 
To support his balance the patient grasps at anything 
that may be near, as a friend's arm or a convenient 
chair. He is unable to walk in the dark, or with his 
eyes shut. A feeling of constriction round the waist 



LOCOMOTOR ATAXY. 287 

is also complained of, as if a cord were drawn tightly 
round it. 

In severe cases the patient cannot stand stead) 7 , cer- 
tainly not with eves shut, nor can he walk on a nar- 
row board, the breadth required being a gauge of the 
severity of the affection. Usually there is diminished 
tactile and muscular sensibility of the lower extrem- 
ities, with numbness or formication. These symp- 
toms may be preceded by transitory pains, as well as 
fleeting phenomena, referable to the cerebrum, or am- 
aurosis, difficult deglutition, etc. Electro-muscular 
contractility remains intact to the last. 

There is no palsy or wasting of the muscles, and, if 
the patient is placed on a chair, you cannot bend his 
legs against his will. 

As the disease progresses it does not stop at the legs, 
but creeps upwards. Arms, hands, and fingers, are 
involved. The coat cannot be buttoned, the pin put 
into the cravat, or the spoon carried to the mouth. 
The urine is passed involuntarily in bed, and now the 
sexual power and appetite are diminished. Thus the 
patient may remain for years. Ultimately the lower 
extremities become thinner, emaciation attacks the 
whole body, and death results from general weakness, 
consumption, or other intercurrent disease. 

It is especially a disease of males, and is rarely met 
with in youth, usually occurring between the ages of 
thirty and fifty years. 

Pathology. — Locomotor ataxy depends on disease of 
the posterior columns of the spinal cord and posterior 
roots of the spinal nerves. There is atrophy and de- 



288 DISEASES OF THE SPINAL CORD. 

generation of the nerve-fibres to a greater or less ex- 
tent, and they become ultimately thin, translucent 
connective tissue cords. The anterior roots of all the 
nerves are normal, and there is also a healthy condition 
of other parts of the nervous system. 

Treatment — The patient should carefully avoid 
overstraining his limbs. Medicinal treatment is essen- 
tially tonic and strengthening. The metallic tonics, 
especially silver, are frequently prescribed. Probably 
the best chance will be afforded by a prolonged and 
careful application of the constant current to the back 
and limbs, which often at least gives relief to the 
neuralgic pains which are frequently so troublesome. 

Cerebro-Spinal Fever, Epidemic Cerebro- 
spinal Meningitis. 

This peculiar disease appears to consist in an inflam- 
mation of the membranes, and sometimes also of the 
substance of the brain and spinal cord. Its origin is 
unknown, its epidemic character undoubted; but its 
contagiousness is questioned. It affects chiefly the 
male sex between fifteen and thirty, if crowded together 
during cold weather, as in barracks or workhouses. 

Symptoms. — The attack is sudden and characterized 
by intense pain in the head, prostration, with spasm 
and rigidity of the muscles of the back of the neck, 
and great sensitiveness of the whole surface of the 
body. The temperature of the body is abnormally 
low at first, and never reaches any great height. A 
peculiar petechial eruption is often present on the 



HYDROPHOBIA. 289 

neck, breast, or limbs, of a red, purple, or black color, 
and varying in size from a pin's head to three-quarters 
of an inch in diameter. The course of the disease is 
rapid, as some die within a few hours, many within 
twelve or twenty-four. The first four days are most 
dangerous; after that time there appears to be a fair 
prospect of recovery. About half of those attacked 
die. 

Treatment is unsatisfactory. Stimulants are recom- 
mended from the outset, with the application of leeches 
behind the ears to relieve the headache, and ice to the 
spine and head to mitigate the spasm. The hypo- 
dermic injection of morphia; chloral and bromide of 
potassium have been strongly urged; and its resem- 
blance to malarial fever has suggested the use of 
quinine. 

Hydrophobia. 

The term hydrophobia was first used by Celsus 200 
B.C., and simply expressed one prominent feature of an 
affection, the pathology of which has ever remained 
obscure, viz., dread of water, or, it may be added, of 
liquids in any form. It is the result of the implanta- 
tion of a specific virus; this inoculation taking place 
most frequently from the bite of a rabid animal, 
especially the dog. The skin must be wounded, and 
its spontaneous development is never known. Wounds 
so occasioned are more dangerous on the hands and 
face than on the lower extremities, probably because 
the clothing worn intercepts the virus. 

After the infliction "of the wound there is a sta^e of 



290 DISEASES OF THE SPINAL CORD. 

incubation, varying from six weeks to as many months, 
daring which time the wound heals perfectly. After 
this a peculiar pricking sensation is felt over the site 
of the cicatrix, accompanied with general symptoms 
of restlessness, depression, and disturbed sleep. On 
these supervene the terribly significant phenomenon 
of dread of liquids and intense thirst. As the disease 
progresses all attempts to drink are avoided. The sight 
even of a drinking vessel containing water is intolera- 
ble, and the patient turns away his face, shrieking out 
at the slightest touch or breath of air. The muscles 
of the neck and trunk, and even the whole muscular 
system, contract spasmodically with convulsive trem- 
bling of the limbs; at times, during the frenzical fits, 
snapping motions are made with the jaws, like biting. 
Although during convulsions mental hallucinations 
occur, yet in the temporary cessation from these the 
patient responds correctly to questions, begs friends 
not to leave him, and with a consciousness of impend- 
ing death, may ask them to pray for him. The saliva 
is now greatly increased in quantity, and, as it cannot 
be swallowed, is ejected in all directions. The respi- 
ration is hurried, and accompanied with a sighing sob. 
This state may continue from one and a half to three 
days, and is succeeded by a stage of paralysis lasting 
two to eighteen hours, with an abatement of the dis- 
tressing symptoms, but greatly increased weakness, 
which deepens into death. The skin is covered with 
a clammy sweat, pulse small and irregular, saliva 
running from the mouth, and accelerated breathing. 



TETANUS. 291 

The duration of the disease in hydrophobia is only 
from two to four days. It always terminates fatally. 

Treatment. — This is of no avail, although many 
remedies have been tried ; yet humanity dictates the 
removal of every cause of excitement, the separation 
of the patient from everything calculated to disturb 
or render him anxious, and the maintenance ~of the 
strength by nutritious enemata during the temporary 
abatement of the spasms, or while under the influence 
of chloroform. 

Tetanus. 

Tetanus may be either idiopathic or traumatic, and 
speaking generally, in both cases seems essentially to 
consist in an inflammatory affection of the spinal cord. 
It is one of the most fatal of maladies, and in its 
idiopathic form appears to be induced by exposure to 
cold or damp, especially in those who have suffered 
from wounds ; it has also apparently been caused by 
worms, by abortion, and by diseases of the womb. 

The first symptom is pain in the epigastric region, 
extending backwards to the spinal column, and due 
to spasm of the diaphragm. Succeeding this are stiff- 
ness of the throat, fixedness of the jaws, and diffi- 
culty of swallowing. Sooner or later there follows 
tonic, i. e., continuous, spasms of the neck, back, and 
loins, causing the body to assume the form of an arch 
(opisthotonos). The skin is hot, the temperature high, 
from 105° Fahr. to 110° Fahr.; wakefulness, thirst, 
and constipation are also prominent symptoms. 
Strychnia poisoning may be mistaken for tetanus, but 



292 DISEASES OF THE SKIN. 

it is distinguished from it by this, that there is no epi- 
gastric pain, spasms are more rapidly developed, and 
do not commence in the jaw. The average duration 
of the disease is from three to five days. Hopes of 
recovery may be entertained if it extends over a week. 
Death results from apnoea or exhaustion. 

Treatment — This is very unsatisfactory. The favor- 
ite remedies, however, are Calabar bean, aconite, chlo- 
ral, bromide of potassium, opium, and chloroform. 



DISEASES OF THE SKIN. 

A few general observations on terms used in skin 
nomenclature will prepare the student for understand- 
ing the classification adopted, and the descriptions, 
necessarily brief, of the various diseases. A series of 
interrogatories may more fully bring out what is 
meant. What is the essential character of an exan- 
thematous affection, apart from the fever which some- 
times accompanies it? It is superficial and red, the 
eruption not being uniform but occurring in patches, 
varying in size and severity, and disappearing under 
pressure. How does it terminate? In resolution, 
the whole exanthem dying away ; or in desquamation, 
scales forming where the eruption formerly was. Thus 
the exanthemata are said to consist of superficial red 
patches, varying in size and severity, disappearing un- 
der pressure and terminating in resolution or desqua- 



GENERAL REMARKS. 293 

mation. Included under this division are erythema, 
'urticaria, and' roseola. The former, speaking generally, 
terminating in resolution ; the latter, as in syphilitic 
roseola, in desquamation. 

What is a vesicle? is it large or small? Small, 
and consisting of a slight elevation of the epidermis. 
But it is more than a slight elevation. It is not solid. 
Prick it and fluid exudes, which is generally trans- 
parent, but sometimes cloudy or sero-purulent. Cover 
one or more rain-drops with skin, and an idea may be 
formed of a vesicular eruption, if you suppose further 
that it may be placed upon skin uninflamed, not red, 
at other times on a red patch. Sometimes the vesicles 
are single, at other times in clusters; sometimes they 
come out at once, sometimes irregularly. With these 
irregularities in situation and in appearance they also 
combine an irregularity in their mode of termination. 
There is fluid in the vesicle. How is it got rid of? 
By absorption or resolution in some instances, the re- 
sult of this being probably a scale where the vesicle 
was ; or it may burst externally, causing excoriation 
of the neighboring parts, and where the vesicle was a 
scab may form, under whose protecting influence the 
new skin is produced. The definition of a vesicle is 
thus seen to be a raising of the epidermis, containing 
fluid, generally serous and transparent, sometimes 
cloudy and sero-purulent. The class vesiculse com- 
prises sudamina, herpes, eczema. 

Bullae may be considered as a sub-order of the 
vesicula?, differing from these as a large umbrella does 
from a small parasol. The bullae or blebs form blad- 

25 



294 DISEASES OF THE SKIN. 

der-like prominences, coming out rapidly, and con- 
taining at first serous fluid, which becomes purulent 
or sero-purulent. The blebs burst, and on the seat 
of the former elevation large black crusts form. The 
rapid formation, the larger size, the more distinct, 
black, crusty scab, and the bad health usually associ- 
ated with them, alone distinguish bullse from vesiculse. 
Under this class are rupia and pemphigus. 

In what way do pustules differ from vesicles? The 
difference seems only one of degree. They are situ- 
ated on a hard, indurated, inflamed base, and the true 
pustule is by Willan said to differ from a vesicle in 
this, that it contains pus from the first moment of its 
formation. Pus cannot be absorbed, and so it seeks 
the surface naturally, aided, as in the case of boils, by 
the lancet, and is followed by scabs or a permanent 
cicatrix on its former site. 

Pustules are therefore defined to be the formation 
between the cuticle and the cutis vera of small tumors 
containing purulent fluid, and terminating by a scab 
or a permanent cicatrix. To this order belong ecthyma 
and impetigo. 

What is a papule or pimple? It is solid; it rs 
small ; it is pointed ; it is raised somewhat above the 
surrounding skin, and as such it can be felt and rec- 
ognized. Retaining its elevated character, in color 
either white or red, attended, as a rule, with itching, 
how does it terminate? Generally by resolution, at 
other times by slight desquamation, and occasionally 
by ulceration. In addition to these characteristics, it 
may be stated that papular diseases are chronic in 



GENERAL REMARKS. 295 

their course, non-contagious, and attended sometimes 
with itching. The diseases under this order are lichen 
and prurigo. 

A scale, in skin nomenclature, means an altered 
epithelial cell, and it may either be primary or sec- 
ondary, i.e., the product of the original disease, or 
coming on as the termination of another skin com- 
plaint. Scales may be produced either by increased 
formation or hypertrophic growth, and may be large 
or small, thick or thin, clear or opaque, crowded 
together in patches or separate. 

The term squamae is applied to scales of degener- 
ated, thickened, dry epidermis, easily detached and 
easily produced. Psoriasis, pityriasis, and ichthyosis 
belong to this order. 

The term tubercle, in skin diseases, must be associ- 
ated with degeneration, this degeneration assuming 
the form of a tumor, which may be small or large, 
more or less prominent, circumscribed in form, and 
persistent, and may lead either to ulceration or sup- 
puration at the summits of the tubercles. The tuber- 
culse are chronic, sometimes hereditary, and in their 
graver forms are peculiar to tropical climates. Under 
the tuberculse are elephantiasis, acne, lupus, mollus- 
cum, frambcesia, keloid. 

The following classification of skin diseases is that 
of Willan considerably modified : 

Order 1. Exanthemata : Erythema, Roseola, Urticaria. 
" 2. Vesiculse: Sudamina, Herpes, Eczema. 



296 DISEASES OF THE SKIN. 

Order 3. Bullae : Pemphigus, Rupia. 
" 4. Pustular : Ecthyma, Impetigo. 
" 5. Parasitici : Tinea tonsurans, Tinea favosa, 

Tinea decalvans, Tinea sycosis, Chloasma, 

Scabies. 
" 6. Papulse : Lichen, Prurigo. 
" 7. Squamse: Psoriasis, Pityriasis, Ichthyosis. 
u 8. Tuberculse: Elephantiasis, Molluscum, Acne, 

Lupus, Framboesia, Keloid. 

Erythema. — There are three chief varieties of 
erythema — 1. Simple erythema, of which a general 
description has been given in the preceding remarks. 
It has a sub-variety, " erythema fugas," so called from 
its shifting character, and its appearing and disappear- 
ing at intervals on different parts of the body. Some- 
times it is observed in fevers on the face, trunk, and 
upper extremities,'and its appearance on such occasions 
forms an element in determining an unfavorable prog- 
nosis. 2. Erythema papulatum is often seen 'in young 
persons at the age of puberty, and is usually associa- 
ted with some disorder of the menstrual or digestive 
functions. Small papules may appear on any part of 
the body, but, as a rule, the sites selected are the back 
of the hands, neck, or face. These papules spread and 
coalesce with one another until the parts affected are 
covered with a red blush, which lasts for a few days 
and then disappears, with some itching. 3. Erythema 
nodosum has a knotty appearance, the knots or patches 
being about one or two inches in diameter, and attacks 
the surface of the legs between the knee and the ankle. 



ROSEOLA — URTICARIA. 297 

The constitutional disturbance is considerable. It is 
peculiar to females between fourteen and twenty, and 
sometimes occurs in an epidemic form. 

Treatment. — Mild saline aperients are serviceable 
for simple erythema (F. 24). Rest in bed and a low 
diet are recommended for "erythema nodosum/' 
Greasy applications in all the varieties mentioned ag- 
gravate the disease. Cloths soaked in whisky and 
water are especially useful in the simple or papular 
form. 

Roseola. — Rose-colored, bright spots, small and of 
various shapes, not much elevated above the surround- 
ing skin, distributed more or less over the body, and 
accompanied by some fever, characterize this affection. 
The roseola seen in infants might be mistaken for 
measles, but it has no regular site for its eruption, at 
times being on the neck or buttocks, and it is unac- 
companied by catarrhal symptoms and attended with 
some itching. 

Treatment. — Alteratives, laxatives, and tonics may 
be required according to the state of the system at the 
time of the roseolar eruption (F. 8). 

Urticaria, or nettlerash, bears, as its name indi- 
cates, more or less resemblance to the eruption pro- 
duced by the application of a common nettle to the 
skin. Hence, wheals or raised elevations are observed, 
of irregular form and uncertain duration, with a white 
centre and red margin, and accompanied by more or 
less tingling and itching, Urticaria may be either 



298 DISEASES OF THE SKIN. 

acute or chronic. In the former the disease runs a 
rapid course and is attended with a smart fever; in 
the latter it is slow, obstinate, persistent, or tending 
to come and go. Both forms seem to be due to errors 
of diet, as eating shellfish, cucumbers, almonds, or 
indigestion and uterine derangements of various kinds. 
Treatment. — In the acute form give an emetic, and 
follow it up by a purgative. In the chronic form at- 
tend carefully to the digestion by ordering a simple 
diet without wine, beer, or spirits, and administer 
laxatives or antacids, with occasional tepid baths. A 
lotion containing prussic acid or perchloride of mer- 
cury is useful in relieving the local irritation (F. 55). 

Sudamhsta are often seen in the form of round, 
pearly vesicles, like drops of water, in the course of 
rheumatic or typhoid fever, phthisis, or any other dis- 
ease with excessive perspiration. 

Herpes. — Groups of vesicles, varying in size from 
a millet seed to that of a pea, are formed on inflamed 
skin. Herpes, in its simplest form, is seen on the lip, 
sometimes in acute pneumonia, or during the progress 
of a common cold, or on the prepuce as the result of 
connection. A more complicated variety is known as 
shingles or herpes zoster. The vesicles in this case 
form a band half encircling the body, and following 
in nineteen cases out of twenty the course of the inter- 
costal nerves on the right side, in the position that 
would be occupied by a sword-belt. The disease lasts 



ECZEMA. 299 

from fourteen to twenty days, and is succeeded by 
scabs. 

Treatment. — Regulate the diet and attend to the . 
bowels. Employ locally the prussic acid lotion, or 
dust the part with starch, three parts, and oxide of 
zinc, one part. If pain be severe, as it sometimes is 
in shingles, it may be necessary to use aconite oint- 
ment, or to inject morphia in the course of the nerve. 
Protecting the part by means of cotton-wool is fre- 
quently very beneficial. 

Eczema consists of an eruption of very minute 
vesicles on various parts of the skin, crowded together, 
and often running into one another in such a manner 
as to present a combination of the various appearances 
of vesicles, pustules, fissures, on an inflamed patch of 
skin. The most distinctive feature of this affection is 
that the vesicles burst, discharging a thin fluid, which 
dries up into yellow crusts. The irritation produced 
by the itching occasions restlessness, and sometimes 
a considerable amount of fever. Various names have 
been given to different varieties. Thus it is termed 
eczema simplex if the vesicles are placed on different 
parts of the skin without any inflammation ; eczema 
rubrum if the skin is inflamed, with heat and swell- 
ing; if engendered by the heat of the sun it is termed 
eczema solare; if by mercury, eczema mercuriale. 

Treatment. — For the eczema which occurs in infants, 
Dr. Erasmus Wilson considers small doses of calomel 
at moderate intervals a specific, followed by Fowler's 
solution, in doses proportionate to the age of the child, 



300 DISEASES OF THE SKIN. 

while the oxide of zinc ointment should be applied 
externally. In the other varieties general measures 
must be trusted to ; saline laxatives, mineral acids, 
sarsaparilla, cod-liver oil. In severe and chronic cases 
the iodide of potassa or Fowler's solution should be 
tried. Locally, employ glycerin, carron oil, or oint- 
ments of oxide of zinc, with prussic acid, or if chronic 
and scaly, the oil of cade may be used. Iodide of sul- 
phur ointment has been recommended, but Dr. McCall 
Anderson prefers soothing applications, of which the 
ungt. diachyli, composed of lead plaster and olive oil, 
is to be preferred. In any case the* patient should be 
strictly enjoined never to bring water in contact with 
the affected part (F. 59, 60, 61, 4). 

Pemphigus. — The eruption, consisting of large 
bullae, is usually preceded by fever and constitutional 
disturbance, and locally by irritation and itching. The 
bullae may be two or three inches in diameter, and 
are either separate or run into one another, and when 
they burst are succeeded by large brown crusts. The 
disease is one of debility, favored by intemperance, bad 
diet, or cold, or it may be due to syphilis. The course 
is chronic. 

Rupia is generally syphilitic in its origin. Small 
flat bullae arise, containing serous fluid at first, which 
degenerates into blood and pus. A thick black scab 
is formed, and beneath it unhealthy ulceration pro- 
gresses, as evidenced by a nasty-smelling discharge. 
The margins of the surrounding skin inflame, more 



IMPETIGO — ECTHYMA. 301 

serum is poured out, and the incrustation takes on a 
stratified appearance, resembling a limpet shell. Its 
duration may vary from two or three weeks to several 
months. 

Treatment. — Both these diseases being attended with 
debility, a generous diet, and fresh air, with wine and 
tonics, are essential. If of syphilitic origin, iodide of 
potassium, with Plummer's pill or the perchloride of 
mercury, may be administered. Locally, poultice, 
and use antiseptic dressings (F. 3, 5). 

Impetigo. — The pustules characteristic of this dis- 
ease are sometimes crowded together, at other times 
distinct, — hence the division into impetigo figurata 
and sparse. In both divisions the pustules break, 
and are succeeded by scabs, with a peculiar candy- 
sugar appearance, if observed on the face. The crusta 
lactea of young children is simply an impetiginous 
eruptive mask. The variety "sparsa" is sometimes 
distributed over a wide area, as the limbs, the body, 
or buttocks. 

Impetigo generally attacks young, scrofulous, ill- 
fed children, or elderly debilitated people. 

Ecthyma may be confounded with impetigo, as 
both diseases are pustular and attended with scabs ; 
but in ecthyma the inflammation is of a more severe 
type and there is more constitutional disturbance. 
The pustules are usually separate, with a hard in- 
flamed base, and terminate with a dark-colored scab. 
The latter leaves superficial ulcers, followed by cica- 

26 



302 DISEASES OF THE SKIN. 

trices. Ecthyma may occur spontaneously, or follow 
the application of some irritant to the skin. 

Treatment. — This is similar to what was mentioned 
in the previous disease, viz., cleanliness, good living, 
and good air, with wine and bark. If the scabs are 
large, apply a charcoal poultice and a sedative oint- 
ment of acetate of lead and lard, or (F. 61). 

Lichen. — -There are two great varieties of lichen, 
"simplex" and "agrius." 

In the former, papules about the size of a millet 
seed are thickly crowded together. In the latter the 
papules are situated on red inflamed skin, and there 
is pain, itching, and tingling, with sometimes fever, 
nausea, and vomiting. The inflammation subsides, 
the papule scales and heals; or by scratching, the 
point of the elevation is torn off, and in consequence 
there is a thin serous discharge, and the skin is left 
fissured with deep and painful cracks. The eruption 
of lichen sometimes subsides in a fortnight, in other 
instances it may extend over some months. It is 
seen most frequently on the hands, arms, and body, 
and constitutes the grocers', bakers', and bricklayers' 
itch. 

Peurigo is a chronic papular affection associated 
with old age and uncleanliness, accompanied with in- 
tense itching, as the result of which the tops of the 
papulesare torn off to the effusion of blood, and the 
blood hardens on the top of the pimple. The appear- 
ance presented by the skin is thus somewhat piebald 
— the bloody-topped papules being situated on dirty 



PSORIASIS — PITYRIASIS RUBRA. 303 

flaccid skin. Prurigo may be mistaken for fleabites, 
but the history of the case will guide to a proper de- 
cision. 

Treatment. — This in lichen is similar to' what has 
been mentioned in the other forms of skin disease, and 
consists in the allaying of irritation by baths, oint- 
ments, etc., etc.; while the digestion is aided by mild 
laxatives and a simple diet. In prurigo, cleanliness 
must be insisted on by means of baths, to which the 
addition of four ounces of carbonate of soda is useful. 
In obstinate cases arsenic or strychnia may be given 
(F. 57, 55). 

Psoriasis is a common chronic skin eruption char- 
acterized by thickened patches of skin varying in size, 
covered by silvery scales, and with a red base. Heal- 
ing commences from the centre to the circumference, 
and there is no tendency to suppuration or ulceration. 
There are two great varieties of psoriasis, syphilitic and 
non-syphilitic — the former occurring most frequently 
on the hands or soles of the feet, the latter on the outer 
aspect of the elbows or knees. A further division has 
also been made into guttata and aggregata, according 
as the patches or scales are put down in a drop form 
or crowded together. 

Pityriasis Rubra. — In the only case I ever saw 
the man stated that his body commenced to itch, and 
he observed in the morning that it was red all over. 
This was followed by thin branny scales, which were 
situated on erythematous skin. The epidermis des- 



804 DISEASES OF THE SKIN. 

quamates in large pieces, so much so that it may sep- 
arate from the foot in the form of a slipper. Another 
variety of pityriasis, called dandriff, is characterized 
by the production of minute white scales, especially 
on the scalp, or parts covered with hair. Another 
form of scaly skin affections is termed ichthyosis, or 
the fish-skin disease, in which the scales are large, 
hard, and dry, resting on an uninflamed surface, and 
unattended with itching or pain. 

Treatment — In psoriasis, non-syphilitic, arsenic 
should be given. In the syphilitic variety the triple 
compound of iodine, arsenic, and mercury (Donovan's 
solution) is requisite. Locally apply, after the scales 
have been removed by poulticing, the oil of cade or 
tar ointment. Tar capsules have also been given 
with advantage. In dandriff, citrine ointment, glyc- 
erin, or (F. 64), does much good. Ichthyosis is con- 
sidered a congenital disease, and hence treatment, by 
means of simple warm and alkaline baths, can only 
be employed in a palliative manner. 

Of the forms of tubercular skin diseases two are 
seen in this country, acne and lupus. 

Acne. — -Acne simplex and acne indurata are com- 
mon at puberty, on the forehead or cheeks. Acne 
rosacea is most frequently associated with good living, 
or with stomach or liver disease. It is sometimes the 
signal-flag of the intemperate. 

Lupus. — Two varieties are lupus exedens and lupus 
non-exedens. The disease in both instances consists 



lupus. 305 

in nodular elevations, which ulcerate in the one case, 
but not in the other. In the non-ulcerative form the 
nodules, which are small, softish, and red, and at- 
tended with no pain, become covered with little white 
scales, then a sort of fatty degeneration occurs, the 
nodules shrink and die away, leaving a loss of sub- 
stance in the form of a depression. In the other form, 
instead of absorption, ulceration sets in, the neighbor- 
ing tissues are invaded, and the edges are thick and 
red. It sometimes destroys the whole nose, including 
the mucous membrane and bones. In both varieties 
it appears to be connected with scrofula, to be most 
common between the ages of fifteen and twenty-five, 
and to affect the face, especially the nose. 

Treatment. — In acne rosacea, if a cure is attempted, 
it is obvious that the diet must be attended to and 
drinking habits stopped ; while in the other varieties 
of acne, friction and gentle stimulation are useful, 
which in the severer forms may be combined with the 
iodide of sulphur ointment (F. 65). In ordinary acne 
the evacuation of the follicles by pressure, succeeded 
by the application of acetic acid lotion, will be fol- 
lowed by good results. The scrofulous nature of lupus 
necessitates tonics, especially cod-liver oil combined 
with acids and bitters. In the severe form, if there 
is any history of syphilis, use Donovan's solution or 
iodide of potass, with sarsapariila. Locally, for the 
non-ulcerating form, Mr. Wilson recommends the 
acetum cantharidis; while for the ulcerating type 
caustic applications are called for, such as chloride of 



306 PARASITICA 

zinc, nitric acid, and potassa fusa, or the surface may 
be scraped by means of a curette. 



PARASITICA. 

Parasitic diseases may either be of animal or vege- 
table origin, and all are contagious, provided the para- 
site is implanted on a suitable soil. 

Scabies depends on the presence of a parasite of 
animal origin, viz., the "acarus scabiei." It most fre- 
quently attacks the flexures of joints; notably it is 
first observed between the fingers, and from thence 
may extend over the whole body with the exception 
of the face, where it is rarely, if ever, seen. The dep- 
osition of the acarus acts as an irritant; a vesicular 
eruption is formed, and this is attended with much 
itching and is specially increased by warmth. Practi- 
cally few people go in for the scientific hunt of the 
acarus, which is the only true evidence of the disease, 
and it is sufficient proof of it if small pointed vesicles 
are observed between the fingers, on the anterior as- 
pect of the forearm, and a pruriginous eruption on the 
inner part of the thigh, attended with much itching. 
A valuable diagnostic sign is the existence of a marked 
eruption at the ulnar side of the wrist and around the 
ankles in children. The presence of furrows with fol- 
liculi (being the female insect covered by epidermis) 



PARASITICA. 307 

at their extremities is of considerable diagnostic im- 
portance. 

Treatment. — The acarus is most easily destroyed by 
the application of sulphur ointment to which a little 
bero;amot has been added to disguise the smell. Two 
or three applications will be sufficient. The clothes 
should afterwards be fumigated by sulphurous acid 
gas, or destroyed. 

The generic term given to the parasites of vegetable 
origin is tinea. 

Tinea favosa commonly affects the scalp in the 
form of a small cup-shaped yellow crust, giving it a 
honeycombed appearance. Each crust contains a hair 
in its centre, and the spores of the fungus are im- 
planted within the follicle. The odor detected is said 
to be like that of cats or mice. 

Tinea Tkicophytixa. — The parasite may attack 
the scalp, hairy part of the face, or general surface of 
the body. 

"When it affects the scalp (tinea tonsurans) it is 
characterized by the appearance of round or oval 
patches of baldness, brittleness or dryness of the dis- 
eased hairs, and round which there are diffused fine 
scales ; when it attacks the hairy parts of the face 
(sycosis menti), by pustular inflammation of the hair- 
follicles in round patches; when it affects the general 
surface of the body (tinea circinata), by rings spread- 
ing from a centre, reddened and raised, and preferring 
those parts of the body which are most exposed. 



308 PARASITICA 

Tinea decalvans, Alopecia areata, commences 
with slight itching and redness. Scales are observed, 
and then the hair falls away, leaving little circular 
bald shining patches, which, however, may so extend 
as to cover a large surface. It affects the beard and 
scalp, and the fungus is not easily detected. 

Tinea versicolor, Chloasma, characterized by 
the appearance of fawn-colored patches on the chest 
and abdomen, which are rough to the touch and cov- 
ered with fine branny scales. 

Treatment. — This must be local and general — local 
to destroy the parasite, general to strengthen the sys- 
tem and prevent the skin forming a suitable soil for 
its development. Thus, poultice to remove scabs, 
then pull out the hair in and around the patches ; sub- 
sequently employ a parasiticide ointment (creasote) or 
sulphurous acid lotion. " Pass a stream of the gas 
through water to saturation; two ounces of this satu- 
rated solution are then added to six ounces of water to 
make the lotion." For tinea versicolor a lotion com- 
posed of two grains of the perchloride of mercury to 
six ounces of water is very serviceable (F. 58). If the 
parasite has thus been destroyed, it is necessary to 
soothe the local irritation by hot cloths, and after- 
wards stimulate by some compound of cantharides, 
vinegar, or rose-water. The general treatment con- 
sists in cleanliness, good hygienic conditions, nourish- 
ing food, cod-liver oil, and iron. In tinea decalvans 
nux vomica and phosphoric acid are recommended. 



APPENDIX. 



FORMULAE. 



The doses in the following prescriptions are intended 
for adults, and it is well for the student to remember that, 
if used for children, the rule suffices to divide the dose 
for an adult, in proportion to the number of years of the 
child's age, increased by 12. 

Thus, for a child of two years, it will be 2 + 12 = 14, 
and this divided by 2 (e. g., T \ths) will make the dose 
^th of that of an adult. 

If for a child of three years, 3 + 12 = 15 (/-ths), or 
|th, etc. 

Opium and its preparations act powerfully on children, 
and hence the dose must be reduced to a greater extent. 

Principal Preparations containing Opium, Mercury, 
Arsenic, etc., with the j^roportions. 

Tinct. Opii contains gr. j in min. xiv. 

Tinct. Camph. Co. contains gr. j in gss. 

Pil. Plumbi c. Opio contains gr. j in gr. viij. 

Pulv. Ipecac. Co. contains gr. j in gr. x. 

Pulv. Kino Co. contains gr. j in gr. xx. 

Enema Opii contains min. xv tinct., or gr. j in gj. 

Liniment. Opii contains two fl. ounces of tincture in ^iv. 

Morph. Acet. Liquor contains gr. iv in one fl. ounce. 

Morph. Hydrochlor. Liq. contains gr. iv in one fl. ounce. 

Inject. Morph. Hypodermica contains gr. j in min. xij. 



310 APPENDIX. 



Mercury. 
Hydrarg. c. Creta contains gr. j in gr. iij. 
Pil. Hydrarg. contains gr. j in gr. iij. 
Liq. Hydrarg. Perchlor. contains gr. -^ in ^j. 

Arsenic. 

(Fowler's Solution.) 
Liquor Arsenicalis contains gr. ^ in min. v. 
Liquor Sodse Arseniat. contains gr. iv in gj. 
Liquor Arsenici Hydrochlor. contains gr. Jj in min. v. 

Strychnia. 
Liquor Strychniaa contains gr. fa in min. v. 

(Donovan's Solution.) 
A fluid drachm contains fa of a grain of arsenic, gr. £ mer- 
cury, and gr. f of iodine. Dose min. x to xxx. 



I.— ALTEKATIVES AND KESOLVENTS. 

Mercury and Iodide of Potassium. 

1. R. Hydrarg. Perchlorid., gr. j ; Potass. Iod., ^iij ; Decoct. 

Sarsaa. Co., ^vj. M. A tablespoonful thrice daily 
after food. 

Mercury and Gentian. 

2. R. Hydrarg. Perchlor., gr. j; Ext. Gentian, £ss. Misce. 

Divide in twelve pills ; one thrice daily. 
Useful in secondary syphilis. 

Donovan } s Triple Solution. 

3. R. Liquoris Hydriodatis Arsenici et Hydrarg., giij ; Tinct. 

Zingib., giij ; Aqua3 ad gvj. Misce. A tablespoonful 
thrice daily after food. 
Useful in secondary syphilis and some skin eruptions. 



APPENDIX. 311 



Arsenic and Cinchona. 

4. R. Liquor. Soda? Arseniatis, gj ; Tinct. Cardamom Co., 

^iij ; Decoct. Cinchon. ad §vj. Misce. A table- 
spoonful thrice daily after food. 

Useful in various skin affections. 

Iodide of Potassium and Calumba. 

5. R. Potass. Iodid , gij ; Infus. Calumbae ad gvj. Misce. 

A dessertspoonful thrice daily. 
Useful in various diseases, syphilitic or otherwise. 

Guaiacum Mixture. 

6. R. Tinct. Guaiaci Co., giij ; Tinct. Aconiti, rn?xx ; Mist.' /£>£» 

Cam ph. ad gvj. Misce. Two tablespoonfuls thrice 
daily. 
Recommended in cynanche tonsillaris and some skin 
affections. 

Chlorate of Potash. 

7. R. Potass. Chlorat., gij ; Syrupi Simplicis, giij ; Aquae/£t/ 

Camph. ad gviij. M. A tablespoonful every four 
hours. 
Recommended in inflammatory affections of the mouth, etc. 

Mercury, Rhubarb, and Soda. a 

8. R. Hydrarg. c. Creta, gr. ij ; Pulv. Rhei, gr. ij ; Sodse Bi- 

carb., gr. iij. M. Make a powder. One at bedtime. 
Recommended in various infantile or children's diseases. 

II.— ANTACIDS. 

Bismuth, Hydrocyanic Acid, etc. 

9. R. Liq. Bismuth. (Scht.), gss* ; Acid. Hydrocyanic. dil. r /4y f 

"n^xl ; Tinct. Card. Co., giij ; Spt. Chloroform., giss. ; 
Aquae ad §yj. Misce. A tablespoonfCil thrice daily 
before food. 
Recommended in dyspepsia for vomiting and pain. 



312 APPENDIX. 

Ammonia, Potash, and Chiretta. 

10. R. Aramon. Sesquicarb., gj ; Potass. Bicarb., 31SS. ; Inf/ f 

Chirettae ad gvj. Misce. A tablespoonful thrice 
daily before food. 
Useful for the acid eructations of dyspepsia and debility. 

Magnesia and Soda. 

11. R. Magnes. Levis, gss. ; Sodae Carb., gr. xx ; Tinct. Au- ILH 

rantii, £ss. ; Aquae Menth. Pip., 3>ijs8. Misce. The 
draught to be taken in heartburn, etc. 

III.— ANTISPASMODICS. 

Lobelia, Ether. 

12. R. Tinct. Lobel., gij ; Spt. Ether. Sulph.,giij; Tinct. Co-/ 4> J 

nii, gij ; Mist. Amygdalae ad £vj. M. A tablespoon- 
ful every three hours. 

In asthma and paroxysmal coughs. 

Cardamoms and Ammonia. 

13. R. Tinct. Card. Co., £iv ; Acid. Hydrocyan. dil., ^xl;/ 4*7-1 

Spt. Ammon. Arom , gij ; Tinct. Zingib., giij ; Spt. 
Chloroform., 31 j ; Aquae Carui ad gvj. M. A table- 
spoonful taken occasionally. 

For flatulence or colic. 



Valerian and Asajoetida. 

14. R. Tinct. Valerian., Tinct. Asafoet, aa Jjij ; Spt. Lavand. 
Co., ^iss. ; Aquae ad §vj. M. A tablespoonful every 
three hours. 

For hysteria, etc. • 



APPENDIX. 313 



Gibb's Nitric Acid Mixture, 

15. R. Acid. Nit. dil., ^xij ; Tinct. Card. Co., giij ; Syrup. 
Simplicis ; giiiss. ; Aquae, §j. M. A teaspoonful every 
two hours. 

For hooping-cough. 



IV.—ASTRINGENTS. 

Sulphuric Acid and Opium. 

16. R. Acid. Sulph. dil., ^iiss. ; Tinct. Opii, £j ; Spt. Chloro- 

form., gij ; Aquae Menth. Pip. ad gvj. M A table- 
spoonful after every liquid stool of adults. 
For diarrhoea. 

Catechu, Opium, and Chalk. 

17. R. Tinct. Catechu, giij ; Tinct. Opii, £j ; Pulv. Aromat., 

^iss. ; Mist. Cretae pd §vj. M. A tahlespoonful 
after every liquid stool of adults. 
For excessive diarrhoea of typhoid fever. 

Chalk Mixture, Cinnamon, and Opium. 

18. R. Tinct. Opii, tr^x ; Pulv. Aromat., 33 ; Mist. Cretae, gvj ; 

Aquae Cinnamomi, giiiss. M. A teaspoonful may 
be given every hour. 

For diarrhoea of children. 

Gcdlic Acid. 

19. R. Acid. Gallici, gr. x; Aquae, giss. M. To be taken 

every four hours. 
Useful in haemoptysis and various haemorrhages. 

Bismuth Mixture. 

20. R. .Bismuth. Subnitrat., 3J : Mucilag. Acaciae, gvj. M. 

A tahlespoonful every three hours. 
Useful in the diarrhoea of phthisis. 



L&0J1 !y-o 



314 APPENDIX. 



Cascarilla, Squills, Dilute Sulphuric Acid, 

21. R. Tinct. Scillse, giss. ; Acid. Sulph. dil., £iss. ; Tinct. Opii, 
gss. ; Inf. Cascarilla? ad Jvj. M. A tablespoonful 
every three hours. 
Useful in chronic bronchitis to check excessive expectoration. 



Starch and Laudanum Enema. 

22. R. Tinct. Opii, £ss.; 01. Terebinth., v% x ; Mucilag. Amyli, 
gij. M. 
It may be employed to check the diarrhoea of typhoid 
fever when excessive. 



V.— CATHARTICS AND ANTHELMINTICS. 

Calomel and Jalap. 

23. R. Calomel, gr. v; Pulv. Jalapae, gr. xv. M. 
An active purgative. 



Sulphate of Magnesia and Sulphuric Acid. 



L« 



•: 



24. R. Magnes. Sulph., gij ; Acid. Sulph. dil., giss. ; Tine 

Card. Co., giss. ; Aqua? Menth. Pip. ad gvj. M. A 
wineglassful every half hour until bowels act freely. 

Aloes , Senna, and Jalap. 

25. R. Tinct. Senna?, Tinct. Jalapse, aa gij ; Decoct. Aloes Co. 

ad gvj. M. An ounce night and morning. 
Useful in bilious headache and constipation. 



Rhubarb, Soda, and Aloes. 

26. R. Extract Rhei, gr. x ; Soda? Phosphat., gj ; Decoct. Aloes 
Co., gss. ; Aqua? Menth. Pip., gj. M. 
A warm aperient, useful in the early stage of gout. 



APPENDIX. 315 

Elaterium and Coloeynth. 

27. R. Extract Elaterii, gr. j ; Ext. Coloeynth. Co., *iiss. ; Ext. 

Hyoseyam., gr. xij. Misce, and divide into twelve 
pills, one night and morning. 

Useful in cardiac or other forms of dropsy. 

Antimony, Sulphate of Magnesia, Citrate of Ammonia, 

28. R. Vin. Antimon., £j ; Magnes. Sulph , gss. ; Liquor Am- 

mon.Cit1at.5iss.; Aquae ad gvj. M. Two table- 
spoonfuls twice or thrice daily. 
Useful as an aperient in the early stages of various disorders. 

29. R. Extracti Filicis Liquidi, ti£xxx ; Pulv. Gum. Acacia?, 

3J ; Aqua? Menth. Pip., §j. Make emulsion. 
Considered a specific in tapeworm. 

30. R. Santonin., gr. ij ; Pulv. Scammon., gr. iij. M. 

Very effectual in expelling the roundworm or thread- 
worm in children. 

YL— DIAPHOKETICS. 

Acetate of Ammonia c. Ether. 

31. R. Liquor. Amnion. Acetat.,gj; Spt. Ether. Nit., gss. ; 

Tinct. Hyoseyam., giij ; Aqua? Camph. ad j|vj. M. 

A tablespoonful every three hours. 
L T seful in febricular and some inflammatory disorders. 

Dover's Powder and Antimony. 

32. R. Pulv. Ipecacuanha? Com., gr. vj ; Antimon. Tartrat., 

gr. J. M. One powder every six hours. 

Guaiacum and Xitre. 

33. R. Pulv. Guaiac, gss. ; Pulv. Potass. Nitrat., Jjj. M. To 

be taken at bedtime (some warm gruel to be taken 
after it). 

Useful in chronic rheumatism. 



316 APPENDIX. 

Ipecac, c. Citrate of Ammonia. 

34. R. Vini Ipecac, giss. ; Syrupi, t ^ss. ; Tinct. Camph. Co., 
giij ; Liquor. Amnion. Cit., §ss. ; Aquae ad gij. M. 
A teaspoonful every two hours. 
Useful in catarrhal and febrile affections of children. 



VII.— DIURETICS. 

Squills, Broom, and Acetate of Ammonia. 

35. R. Tinct. Scillae, gij ; Liq. Amnion, Acetat., gij ; Decoct. 

Scoparii ad ^vj. M. Two tablespoonfuls thrice 
daily. 
Useful in dropsy dependent on heart, liver, etc. 

Mercury, Squills, and Digitalis. 

36. R. Pil. Hydrarg., £ss ; Pulv. Scillse, gr. vj ; Pulv. Digitalis, 

gr. xij. M. Divide into twelve pills. One twice 
daily. 
Useful in pleurisy or pericarditis to remove effusion. 

Acetate of Potass, Squills, and Digitalis. 

37. R. Potass. Acet.,£ss. ; Acet. Scillae, ^ss. ; Spt. Ether. Nit., 

Tt£xx ; Tinct. Digitalis, njjv ; Decoct. Scoparii, giss. 
M. The draught thrice daily. 
37a. R. Potass. Acetat., giij ; Potass. Citrat., spij ; Inf. Digi- 
talis ad gvj. M. A teaspoonful every three hours. 

Bitartrate of Potass and Buclxu. 

38. R. Potass. Bitart., giij ; Inf. Buchu ad gvj. M. Two 

tablespoonfuls thrice daily. 
Useful as a diuretic, and where there is very acid urine 
with an excessive secretion of uric acid. 



APPENDIX. 317 



Oil of Juniper, Nitric Ether, and Digitalis. 

39. R. Olei Juniperi, £ss. j Spt. iEtheris Nit., Yini Ipecac, 

Tinct. Digitalis, aa ^iij. M. Twenty-five drops 
every three hours. 
Diuretic, and in some cases also useful as an emmenagogue. 

Nitrate of Potass and Barley Water. 

40. R. Potass. Nitrat., gij ; Acid. Nit. dil., 33. To be put into 

a pint of barley water and drunk daily. 
Useful in the early stages of fever. 



YIIL— EMETICS AND EXPECTORANTS. 

Antimonial or Jpecacuan Emetic. 

41. R. Antimon. Tartratis, gr. j ; Yin. Ipecac, gj ; Aquae ad 

giss. M. 

vel 

42. R. Yin. Ipecac, gj. 

Either of these draughts w 7 ill relieve the stomach. They 
are sometimes recommended in the early stages of 
fevers, etc 

Toln, Ammoniacum, and Opium. 

43. R. Syrupi Tolutani, ^ss. ; Mist. Ammoniaci, §ij; Tinct. 

Camph. Co., ^iij ; Aquae ad £vj. M. A tablespoon- 
ful three times a day. 

Useful in chronic bronchitis. 

Ammonia, Squills, and Senega. 

44. R. Ammonia? Carbonatis, £j ; Tinct. Scillae, ^iij ; Tinct. 

Camph Co., gss. ; Decoct. Senegae ad gvj. M. A 
tablespoonful every four hours. 
A stimulating expectorant in various chest affections. 
27 



318 APPENDIX. 

Ipecac, Tolu, and Acacia. 

45. R. Yin. Ipecac, gij ; Syrup. Tolutani, ^iv; Mucilag. 

Acaciae ad §ij. M. A teaspoonful every hour or 
every second hour. 
Useful in acute bronchitis or measles with chest symptoms. 

Lobelia, Spirit Chloroform, and Conium. 

46. R. Tinct. Lobelia, gij ; Spt. Chloroform., giij ; Tinct. 

Conii, giij ; Mist. Amygdalae ad gvj. M. A table- 
spoonful three times a day. 

Useful in asthma, etc. 

IX.— GAKGLES AND INHALATIONS. 

Tannin Gargle. 

47. R. Tannin, gj ; Aquae Camph.,gvj. M. The gargle to be 

used frequently. 

48. R. Tinct. Myrrbae, ^iij ; Aluminis, ^j ; Infusi Kosae Acidi 

ad gvj. M. To be used frequently in mercurial sali- 
vation, or scarlatinous or aphthous ulceration of the 
throat. 

Tannin and Glycerin. 

49. R. Tannin, gss. ; Glycerini, giv. M. The throat to be 

touched witfr this twice or thrice daily in scarlet 
fever, etc. 

Borax and Glycerin. 

50. R. Sodae Biborat., 3J ; Glycerini, gij. M. 

Useful in ulceration of mouth and throat. 

Nitrate of Potash. 

51. R. Potass. Nitrat., gj ; Aquae, gj- Saturate white blotting- 

paper in this solution, and dry it; cut the paper into 
pieces 3 inches long, J inch broad. One piece may be 
lighted, and the smoke inhaled. One to six papers 
may be used in succession for each inhalation. 
Recommended as an antispasmodic in asthma. 



APPENDIX. 319 



Hop Inhalation. 

52. R. 01. Humuli, gss. ; Magnesiae Carb. Pond., gj. M. Aquae 

ad !§iij. M. A teaspoonful to be put into a pint of 
boiling water, afterwards used by Maw's inhale*. 
Useful in phthisis, where cough is irritable, and in 
various chest affections. 

Creosote and Carbolic Acid Inhalation. 

53. R. Creasot., giij ; Magnes. Carb. Pond., giss. ; Aquae ad 

giij. M. ; or, 
53a. R. Acid. Carbolici, gj ; Aquae, gvij. M. • A teaspoonful 
in a pint of water at 150° F. for each inhalation. 
Useful in chronic congestion of the larynx. 

Pine Inhalation. 

54. R. 01. Pini Sylvestris, spj ; Carb. Magnes. Pond., gj ; Aquae 

ad 3 iij . M. A teaspoonful in a pint of water at 
150° F. for each inhalation. 



X.— LOTIONS, LINIMENTS, Etc. 

Prussic Acid and Perchloride of Mercury. 

55. R. Hydrarg. Perchlor., gr. ij ; Acid. Hydrocyanici dil., 

gj ; Mist. Amygdalae ad gvj. M. 
Useful in prurigo, and various skin affections attended 
with itching. 

Prussic Acid and Potass. 

56. R. Liquoris Potassae, gij.j Acid. Hydrocyanici dil., £j ; 2?f 

Aquae ad gvj. M. 

Useful in pityriasis. 
5Ga. R. Acid. Carbolic i, gr. viij ; Glycerini, gss. ; Aqua? ad 

Applied to pustules in small-pox. 



320 APPENDIX. 

Soda and Glycerin. 

57. R. Sodse Bicarb., gj ; Glycerini, giss. M. 

Useful in the itching of cutaneous diseases. 

Perchloride of Mercury. 

58. R. Hydrarg. Perchlor., gr. j ; Aquae ad §ijss. 

Useful in tinea favosa in children, or in chloasma in adults. 

XI.— OINTMENTS. 

59. R. 01. OlivEe, §xij : Litharg., giij. M. S. A., and add 01. 

Lavand., gij. 

Apply on linen twice daily in eczema. 

60. R. 01. Cadini, Spt. Vini Kect., Sapon. Mollis, aa gj ; Spt. 

Lavand., giiss. M. 
Kecommended by Dr. McCall Anderson in eczema. 

Bismuth, Zinc, Prussic Acid. 

61. R. Bismuthi Trisnitrat., 3 j ; Ungt. Zinc. Ox., gj ; Acid. 

Hydrocyanici dil., gj. M. 

Useful in various skin affections. 

62. R. Balsami Tolutani, ^ij ; Olei Eosmarini, tr^xx ; Tinct. 

Cantharid., Jj ; Olei Kicini, gss. ; Adipis Prep., ^iss. 
M. 
To be rubbed on night and morning to roots of hair in 
cases of baldness, after syphilis, fevers, etc. 

Aconitia and Iodine. 

63. R. Aeonitise, gr. ij ; Ungt. Iodi, gj. M. To be painted ^' 

over part in severe neuralgia (tic douloureux). 

Citrine Ointment 

64. R. Ungt. Hydrarg. Nit., £j ; Adipis, §j. M. 

Used in vesicular, squamous, and some parasitic affections. 



APPENDIX. 321 



Iodide of Sulphur Ointment. 

65. R. Iod. Sulpb., gr. x ; Sulph. Sublim., gr. x ; Acid. Hydro- 
cyan, dil., ™£x ; Adipis, §j. M. 

Used in acne and other skin affections. 



XII.— SALINES. 

66. R. Spt. Ammon. Aromat., giij ; Liq. Ammon. Cit., §fv; /^ 

Syrup. Limon., gj ; Aquae ad ^viij. M. A table- 
spoonful every three or four hours. 
Useful in early stages of tonsillitis, diphtheria, or in febricula. 

Chlorate of Potash {Fever Drink). 

67. R. Potass. Chlorat.. 3J ; Aquae ad Oj. M. 
Recommended as a daily drink in scarlet or other fevers. 

Colchicum and Magnesia. 

68. R. Yini Colchici, gjss. ; Magnes. Carb., 31 j ; Aquae ad Jvj. 

M. A tablespoonful every three hours. 
Useful in gout. 
Or, 
68a. R. Yini Colchici, g?s. ; Magnes.,gr. xv ; Magnes. Sulphat., 
3J ; Aquae Cinnamom. ad 3 i j . M. 
This draught is recommended by Sir Charles Scudamore 
during the paroxysms of gout. 



XIII.— SEDATIYES. 

Bromide of Potash and Chloral. 

R. Potass. Bromid , Jiij ; Chloral Hydrate, gj ; Aquae ad 
§vjsa — A tablespoonful every two hours. 
Useful in delirium tremens, and also in fevers with 
great restlessness. 



322 APPENDIX. 



Opium and Antimony. 

70. R. Tinct. Opii, 31 j ; Antimonii Tartar., gr. iv ; Aquae 

Camph. ad §vj. M. A tablespoonful every two 
hours until sleep is produced. 

Useful in delirium tremens. 

Morphia and Hydrocyanic Acid. 

71. R. Morphise Hydrochlor., gr. j; Acid. Hydrochlor. dil., 

tt£v; Acid. Hydrocyan. dil., gss. ; Syrup. Scillse, gj ; 
Aquae, §j. M. One teaspoonful to be taken when 
cough is very severe, as in advanced cases of phthisis. 

Bromide of Potass and Ergot. 

71a. R. Potass. Bromide, jjiij ; Extract. Ergotae Liquid., 31J ; Z? 
Aquae ad §vj. M. A tablespoonful three times a 
day. 
Useful in cerebral congestion, and also in infantile spinal 
paralysis in earty stage. 

XIV.— STIMULANTS. 

Spirit of Chloroform and Brandy Mixture. 

72. R. Spt. Chloroform., gij ; Mist. Spt. Vini Gallici ad gvj. 

M. A tablespoonful every two hours in the low stages 
of fevers or other exhausting diseases. 

Ammonia, Potash, and Rhubarb. 

73. R. Spt. Amnion. Arom., Liquor. Potass., Tinct. Ehei, aa 

gj. M. A teaspoonful twice a day in water, as an 
antacid stimulant and stomachic. 

Soda and Calumba. 

74. R. Sodae Bicarb., 3J ; Tinct. Calumb., gvj ; Aquae Anethi 

ad gvj. M. A tablespoonful every three hours. 
Useful to relieve heartburn and nausea. 



APPENDIX. 323 

XV.— TONICS. 

Quinine Mixture. 

75. R. Quiniae Sulphatis, gj ; Acid. Sulph. dil., giss. ; Syrup. 

Aurant., Tinct. Aurant., aa giv; Aquae ad gvj. M. 
A tablespoonful three times a day. 

Quinine and Ammonia. 

76. R. Ferri et Quiniae Citratis, giss. ; Amnion. Carbonatis, gij ; 

Tinct. Aurantii, Jij ; Aquae, Jij. M. A tablespoon- 
ful three times a day. 

Quinine and Gentian. 

77. R. Ferriet Quiniae Citratis, Ext. Gentian., aagss. M. To 

be divided into twelve pills. One to be taken twice 
a day. 

Iron and Hydrochloric Acid. 

78. R. Tinct. Ferri Perchlor., giss. ; Acid. Hydrochlor. dil., 

g j ; Tinct. Hyoscyam., g j ; Inf. Calumb. ad gvj. 
M. A tablespoonful three times a day. 

Iron, Calumba, and Glycerin. 

79. R. Tinct. Ferri Perchlor., gij ; Tinct. Calumbae, giij ; Glyc- 

erini, gij ; Aquae ad gvj. M. A tablespoonful three 
times a day. 
Useful in anaemia, and sometimes also in phthisis. 

Strychnia and Nitric Acid. 

80. R. Liquor. Strychnia?, gj ; Acid. Nitric, dil., giss. ; Acid. 

Hydrochlor. dil., giss.; Tinct. Zingiber., giiiss. ; 
Syrup. Croci, giij ; Aquae ad gvj. M. A table- 
spoonful three times a day. 

Useful in some special affections. 



324 APPENDIX. 



Syrup of Iodide of Iron and Cod-liver Oil. 

81. R. Syrupi Ferri Iodidi, giij ; Mucilag. Acaciae, gj ; 01. 

Morrhuao, givss. M. A tablespoonful three times a 
day. 

Hypophosphite of Lime and Glycerin. 

82. R. Calcis Hypophosphitis, ^j ; Glycerini ad gvj. M. A 

tablespoonful three times a day. 



Iron and Gentian. 

83. R. Ferri Sulphatis, Ext. Gentian., aa Jss. M. Divide 
into twelve pills ; one twice daily. 



Citric Acid, Citrate of Iron, Bismuth, and Prussic Acid. 

84. R. Ferri Citratis, ^iss. ; Acid. Citrici, gvj ; Aquae ad gvj. 

M. Acid. Hydrocyanici dil., fl^lxxij ; Potass. Bicarb., 
gvj j Liq. Bismuth., Syrup. Aurantii, aa giij. M. 
A dessertspoonful of the contents of each in a glass of 
water thrice daily. 
Recommended in dropsy from granular kidney. 

85. R. Strychnias, gr. j ; Ferri Pyrophosphatis, Qniniae Sulph., 

aa ^j ; Acid. Phos. dilut., Syrup. Zingiber, aa §ij. 
M. A teaspoon ful three times a day in a little 
water. 
Recommended in some nervous affections when strychnia 
is required. 

86. R. 01 ei Phosphorat., gs's. ; Mucilag. Acaciae, gj ; Olei Ber- 

gamot., gtt. xl. M. Twenty-five drops three times 
a day. 
Useful in nervous affections requiring phosphorus. 



APPENDIX. 325 

Salicylic Acid Mixture. 

R. Acid. Salicylici, gij ; Potass. Acetat., ^iss. ; Aquse ad 
gvj. M. A tablespoonful every three hours. 
Recommended in rheumatic fever. 
R. Salicin, gr. xx. One every three hours. 



Digitalis and Iron. 

3. R. Tinct. Ferri Perchlor., ^ij ; Inf. Digital, ad gvj. M. 
A dessertspoonful thrice daily. 



Ammonia, Citrate of Iron, and Calumba. 

90. R. Ferri Ammon. Citrat, £j ; Tinct. Calumbae, giij ; Aquas 
Camph. ad gvj. M. A tablespoonful thrice daily. 
Useful tonic in kidney disease, etc. 



Rhubarb and Pepsin. 

91. R. Pulv. Rhei, gr. iv ; Pepsin, gr. iij. M. 

Useful in dyspepsia with flatulence. To be taken after 
meals. 



Test for Diabetic Urine. 

92. Fehling's Standard Solution is prepared according to the 
following prescription : Sulphate of Copper, 90J 
grains ; Neutral Tartrate of Potash, 364 grains ; Solu- 
tion of Caustic Soda, sp. gr. 1.2, 4 fluid ounces; add 
water to make up exactly 6 fluid ounces. 200 grains 
of this solution are exactly decomposed by one grain 
of sugar. 



28 



INDEX. 



Abdominal aorta, aneurism of, 

161 
Abdominal diseases, physical diag- 
nosis of, 16 
Abscess of brain, 259 

of kidney, 223 

of liver, 205 

of lung, 124 

of spleen, 34 
Acarus scabiei, 306 
Acne, 304 
Acute atrophy of liver. 206 

desquamative nephritis, 224 

tubal nephritis, 224 
Addison's disease, 216 
Adherent pericardium, 149 
^Egophony, 125. 131 
Ague, 35 

Ague spleen or cake, 37, 213 
Albumen in urine, 220 
Alopecia areata, 308 
Alteratives, 310 
Amphoric respiration, 139 
Amyloid liver, 200 

kidney, 229 
Anaemia, 85 

cerebral, 244 
Anaemic murmur, 86 
Anaesthesia, hysterical, 281 
Anasarca, 58 

scarlatinal, 50 
Aneurism, abdominal. 161 

miliary, 247 

thoracic, 159 
Angina pectoris, 142 
Anginosa scarlatina, 50 
Antacids, 311 
Anthelmintics, 314 



[ Antiscorbutics, 82 
Antispasmodics, 312 
Aorta, aneurism of, 159, lfil 
Aortic valves, disease of, 156 
Aphasia, 255 
Aphonia, 255 
Aphthae of the mouth, 164 
Apoplexy, 250 

diagnosis of, 251 

meaning of, 250 
Apoplectic seizure, 251 
Arsenic, preparations containing, 

310 
Articular rheumatism, 72 
Ascaris lumbricoides, 191 
Ascites, 59 

diagnosis of, 60 
Asthma, 121 

idiopathic or spasmodic, 121 

symptomatic or organic, 121 
Astringents, 313 
Athetosis, 276 
Atrophy of heart, 147 

of liver, acute and simple, 206 
Aura epileptica, 270 
Auscultation, 15, 91 

Bakers' itch, 302 

Basedow's disease, 216 

Baths, use of, in fevers, 27, 33, 38, 

40, 52 
Bell's paralysis, 263 
Bengal fever, 38 
Biliary calculi, 209 

colic, 210 

ducts, catarrh of, 204 
Bilious fever, 22 

remittent fever, 23 



328 



INDEX. 



Black measles, 55 

vomit, 41 
Bladder, haemorrhage from, 234 
Bleeding from kidney, 234 

from lung, 137 

from stomach. 137, 170 
Blood, excess of white cells in, 214 

in urine, 220, 234 

poverty of, 85 

spitting of, 136 

vomiting of, 137, 170 
Bothriocephalus latus, 190 
Bowels, obstruction of, 176 

perforation of, 198 
Brain, abscess of, 259 

anaemia of, 244 

congestion of, 245 

diseases of, 243 

fever, 22 

haemorrhage into, 247 

inflammation of, 259 

sclerosis of, 253 

softening of, 252 

syphilitic tumors of, 68 

tumors of, 259 
Bricklayers' itch, 302 
Bright's disease, 224 

acute, 224 

chronic, 226 

morbid anatomy of, 226 

treatment of, 229 
Bronchial dilatation, 116 

fistula, 130 

respiration, 92 
Bronchiectasis, 116 
Bronchitis, 112 

acute, 112 

chronic. 116 

varieties of, 112 
Bronchocele, 215 
Bronchophony, 92 
Bruit, aneurismal, 161 

de diable, 86 

de pot fele, 139 
Bullae, 293, 300 

Calculus, biliary, 210 

in kidney, 236 

urinary, 236 
Cancer of brain, 259 

of kidney, 237 

of liver, 204 

of lung, 142 



Cancer of oesophagus, 166 

of stomach, 172 
Cancrum oris, 164 
Capillary bronchitis, 112 
Cardiac dropsy, 60 

murmurs, 152 

diagnosis of, 155 
functional and organic, 157 
treatment of, 158 
Cardialgia, 168 
Carpopedal spasms, 106 
Case-taking, 14 
Cataract in diabetes, 242 
Catarrh, 95 

of bile-ducts, 204 
Catarrhal fever, 22 

pneumonia, 126 
Cathartics, 314 
Cavernous respiration, 91 
Cerebral anaemia, 244 

congestion, 245 

embolism and thrombosis, 246 

haemorrhage, 247 

meningitis, 256 

paralysis, 260 
Cerebral sclerosis, 253 

softening, 252 
Cerebro-spinal fever, 288 

meningitis, 288 
Chalkstones, 76 
Chicken-pox, 48 
Chloasma, 308 
Chlorosis, 85 
Cholera, English, 180 

epidemic, 184 
Chorea, 274 
Chronic atrophy of liver, 206 

bronchitis, 116 

gout, 76 

hydrocephalus, 258 

peritonitis, 196 

pleurisy, 134 

rheumatism, 71 
Chylous urine, 232 
Cirrhosis of the liver, 207 
Classification of disease, 13 
Coecum, disease of, 197 
Coffee-grounds, vomiting, 173 
Colic, 175 

biliary, 210 

lead, 176 

renal, 236 
Condylomata, treatment of, 70 



INDEX. 



329 



Congestion of liver. 203 

of spinal cord, 284 
Constipation, 1 74- 
Consuinption, 136 
Continued fever, 21 
Contracting or granular kidney, 

22S 
Convulsions, uremic, 231 
Corvza, 95 
Coup de Boleil, 279 
Cow-pox. 47 
Crepitatio redux, 125 
Crepitation. 93 
Croup, diagnosis of, 103 

false. 106 

true, 102 
Croupous inflammation, 103 
Crusta lactea, 301 
Cutaneous affections, ^syphilitic, 69 
Cynanche parotidea, 165 

tonsillaris, 165 
Cysticercus cellulosse, 190 

Dandriff, 304 
Dandy fever, 42 
Delirium tremens, 276 
Dengue. 42 
Derbyshire neck, 215 
Diabetes, 237 

cataract in, 242 

insipidus, 238 

mellitus. 238 
Diagnosis, general remarks on, 13 

physical, 14, 91 
Diaphoretics. 315 
Diaphragmatic pleuris} 7 , 132 
Diarrhoea., simple, 180 

typhoid, 29 
Diathesis, gouty, 77 

scrofulous, 65 

tubercular, 62 
Diffuse sclerosis, 253 
Digestive organs, diseases of, 166 
Dilatation of heart, 145 
Diphtheria, 98 

diagnosis of, 103 
Diphtheritic inflammation, 99 
Disease, meaning of term, 13 
Diseases, general. 13 

of circulatory system, 14, 143 

of digestive system, 14, 166 

of genito-urinary system, 14, 
218 



Diseases of integumentary system, 
14, 292 

of nervous system, 14, 243 

of respiratory system, 14, 91 
Diuretics, 316 
Donovan's solution, 310 
Dropsy. 58 

active, 59 

acute, 59 

cardiac. 60 

chronic. 59 

diagnosis of, 60 

hepatic. 60 

of the kidney, 237 

passive. 59 

renal, 60 

scarlatinal, 50 

treatment of, 61 
Dropsical fluid, characters of, 61 
Drop wrist, 176 
Dysentery. 181 
Dyspepsia, 166 

strumous, 65 

Echinococci, 201 
Ecthyma. 301 
Eczema, 299 

Embolism and thrombosis, cere- 
bral, 246 
Emetics. 317 
Emphysema, 118 

interlobular, 119 

lobular. 119 

senile, 120 
Empyema, 130 
Encephalitis, 259 
Endemic disease, meaning of, 19 
Endocarditis, 151 

rheumatic, 72 
English cholera, 180 
Enteric fever, 27 

ulcer, 29 
Epidemic catarrh, 110 

cholera, 184 

meaning of, 19 
Epilepsy, 269 
Eruptive fevers, 43 
Erysipelas, 87 

diagnosis of, S9 
Erythema, 296 
Etiology, 20 
Exanthemata, 292, 295 
Exophthalmic goitre, 216 



330 



INDEX. 



Expectorants, 317 

Facial neuralgia, 268 

paralysis, 263 
Falling sickness, 269 
False croup, 106 
Famine fever, 33 
Fatty degeneration of heart, 147 
of kidney, 227 
of liver, 201 

growth of heart, 148 

stools, 212 
Favus, 307 
Febricula, 21 
Fever, cerebro-spinal, 288 

continued, 21 

generally, 21 

dengue or dandy, 42 

intermittent or ague, 35 

relapsing, 33 

remittent, 38 

scarlet, 49 

simple, 21 

typhoid, 27 

typhus, 23 

yellow, 40 
Fevers, eruptive, 43 
Fibroid pneumonia, 127 
Fish-skin disease, 304 
Fistula, bronchial, 130 
Fits, apoplectic, 251 

epileptic, 270 

hysteric, 281 
Flatulence, 167 
Follicular stomatitis, 164 
Formula, 309 
Friction-sound, cardiac, 150 

pulmonary, 130 

Gallstones, 210 

Gangrene of the lung, 126 

Gangrenous stomatitis, 164 

Gargles, 318 

Gastralgia, 167 

Gastric fever, 27 
ulcer, 169 

Gastrodynia, 168 

Gastrotomy, 180 

General diseases, 14, 18 

paralysis of insane, 261 
remarks on diagnosis. 14 

Gin-drinker's liver, 207 

Globus hystericus, 281 



Glosso-labio-laryngeal paralysis, 

265 
Glottis, oedema of the, 96 
Glycosuria, 238 
Goitre, 215 
Gout, 74 

diagnosis of, 78 

retrocedent, 77 
Gouty asthma, 77 

diathesis, 77 

kidney, 77, 228 
Granular or contracting kidney. 

228 
Gravedo, 95 
Gravel, 236 
Graves's disease, 216 
Gray hepatization of lung, 124 

tubercle, 63 
Gummata, 68 

Haematemesis, 137, 170 

treatment of, 171 
Haematinuria, 235 
Haematuria, 234 
Haemoptysis, J 37 
Haemorrhage, cerebral, 247 

from kidney, 234 

from lungs, 137 

from stomach, 137 

into spinal cord, 284 
Heart, angina pectoris, 142 

atrophy of, 147 

dilatation of, 145 

diseases of, 142 

fatty degeneration of. 147 

fatty growth of, 148 

hypertrophy of, 144 

murmurs, 152 

palpitation of, 159 

valvular diseases of, 152, 155 
Heartburn, 168 
Heat apoplexy, 279 
Hemichorea, 275 
Hemiplegia, 261 
Hepatic abscess, 205 

congestion, 203 

diseases, 199 

dropsy, 60 
Hepatitis, 205 
Hepatization of lung, 124 
Herpes, 298 

zoster, 298 
Hobnailed liver, 207 



INDEX. 



331 



Hollow worms, 189 
Hooping-cough, 107 
Hydatid vibration, 202 
Hydatids of kidney, 237 

of liver, 201 
Hydrocephalus, 59 

acute. 257 

chronic. 258 
Hydronephrosis, 237 
Hydropericardium, 59 
Hydrophobia, 289 
Hydropneumothorax, 130, 136 
Hydrothorax, 59. 136 
Hypertrophy of heart. 144 

simple, of liver, 202 
Hysteria, 279 

Ichthyosis, 304 

Icterus, 208 

Idiopathic asthma, 121 

Ileum, typhoid ulceration of. 29 

Ileus. 177 

Impetigo, 301 

Incubation, periods of, 44 

Indigestion, 167 

Infantile paralysis, 266 

Inflammation of bile-ducts, 204 

of brain, 259 

of bronchial tubes, 112 

of ccecum, 198 

of endocardium, 151 

of kidney, 222 

of larynx, 96 

of liver, 205 

of lungs, 122 

of meninges of brain, 256 

of mouth, 164 

of parotid, 165 

of pericardium, 148 

of peritoneum, 194 

of pleura, 129 

of spinal cord, 283 

of tonsil, 165 
Inflammatory croup, 102 

softening of brain, 252 
Influenza, 110 
Inhalations, 318 
Insane, general paralysis of, 261 
Insolatio, 279 

Interlobular emphysema, 119 
Intermittent fever, 35 
Internal gout, 77 
Interstitial pneumonia, 127 



Intestinal obstruction, 176 

worms, 189 
Intussusception, 177 
Inunction of mercury, 69 
Itch, 306 

Jaundice, 208 
Jungle fever, 38 

Kidney, Bright's disease of. 224 
Bright's disease of, acute. 224 
Bright's disease of,chronic, 226 
calculus of, 236 
cancer of, 237 
congestion of, 222 
contracting, 228 
dilatation of. 237 
diseases of, 217 
dropsy of, 237 
granular disease of, 228 
hematuria from, 233 
hydatids. 237 
inflammation of, 222 
lardaceous or waxy, 227 
large, white, 227 
movable, 237 
tubercular disease of, 237 

Lardaceous liver, 200 
Large white kidney, 227 
Laryngismus stridulus, 106 
Laryngitis, acute and chronic, 96 
Larynx, diseases of, 96 
Latent pleurisy, 132 
Lead colic, 176 

palsy, 176 
Leucocythaemia, 214 
Leukaemia, 214 
Lichen, 302 
Liniments, 319 
Liver, abscess of, 205 

amyloid, lardaceous, or waxy, 
200 

atrophy, simple and acute, 206 

cancer of. 204 

catarrh of bile-ducts, 204 

cirrhosis of, 207 

congestion of, 203 

contractions of, 206 

diseases, 199 

fatty, 201 

hydatid tumor of, 201 

hypertrophy, simple, of, 202 



332 



INDEX. 



Liver, inflammation of, 205 

painful enlargements of, 203 
painless enlargements of, 200 
pysernic and tropical abscess 

of, 204 
syphilitic tumors of, 68 

Lobular emphysema, 119 

Local paralysis, 260 

Locked jaw, 291 

Locomotor ataxy, 286 

Lotions, 319 

Lumbago, 268 

Lungs, cancer of, 142 
diseases of, 112 
emphysema of, 118 
gangrene of, 126 
inflammation of, 122 
tubercular disease of, 63, 136 

Lung-tissue, detection of, in spu- 
tum, 140 

Lupus, 304 

Malaria, 36 
Marsh miasm, 36 
Measles, German, 56 

true, 55 
Meningitis, acute, 256 

cerebro-spinal, 288 

chronic, 258 

spinal, 283 

tubercular, 257 
Mensuration, 16, 94 
Mercurial palsy, 265 
Mercury, preparations containing, 

310 
Mesenteric fever, 22 
Miliary aneurisms, 247 

tubercle, 63 
Mitral valve, disease of, 155 
Morbilli, 53 
Morbus Addisonii, 216 

Brightii, 224 

regius, 209 
Morphia, preparations containing, 

309 
Motor oculi, paralysis of, 264 
Mouth, diseases of, 164 
Movable kidney, 237 
Muco-crepitant rales, 95 
Multiple cerebro-spinal sclerosis, 

253 
Multiple sclerosis, 253 
Mumps, the, 165 



Myelitis. 283 

Nausea, 167 
Nephralgia, 236 
Nephritis, 222 

acute desquamative, 224 

acute tubal, 224 

suppurative, 222 
Nervous system, diseases of, 243 
Nettlerash, 297 
Neuralgia, 267 
Non-inflammatory croup, 106 

softening of brain, 252 

softening of spinal cord, 285 
Nummular sputum, 138 

Obstruction of the bowels, 176 
(Edema, 58 

glottidis, 96 
(Esophagus, diseases of, 166 
Oidium albicans, 164 
Ointments, 320 
Opisthotonos, 291 
Opium, preparations containing, 

309 
Organic asthma, 121 
Oxalate of lime in urine, 219 
Oxyuris vermicularis, 192 

Painters- colic, 176 
Palpation, 16 

Palpitation of the heart, 159 
Palsy, wasting, 265 
Pancreas, diseases of the, 211 
Papular eruptions, 302 
Papule, description of, 294 
Paracentesis thoracis, 135 
Paralysis, 260 

agitans, 254 

diphtheritic, 102 

facial or Bell's, 263 

glosso-labio-laryngeal, 265 

infantile spinal, 266 

lead, 176 

mercurial, 265 

of the insane, 261 

of the third nerve, 264 

varieties of, 260 

wasting, 265 
Paraplegia, 262 
Parasitic eruptions, 306 

plants, 307 
Paresis, 260 



INDEX. 



333 



Parotid, inflammation of the, 165 
Passive dropsy, 59 
Pectoriloquy, 92 
Pemphigus, 300 
Percussion of chest, 16, 95 
Perforation of bowels, 198 

of stomach, 170 
Pericarditis, 148 
Peritonitis, 194 

acute, 195 

chronic. 196 

tubercular, 197 
Perityphlitis, 197 
Petechia;, 82 
Peyer's patches, typhoid ulcers of, 

30 
Phthisis, 136 

acute, 140 
Physical diagnosis, 14, 91 
Pityriasis, 303 
Plague, 43 
Pleurisy, 129 

acute, 129 

chronic, 134 

diagnosis. 132 

diaphragmatic, 132 

latent, 132 
Pleurodynia, 268 
Pleuropneumonia, 126 
Pneumonia, 122 

catarrhal, 127 

fibroid, 127 

interstitial, 127 
Pneumothorax, 130, 136 
Podagra, 97 
Polypi of larynx, 97 
Preparations containing opium, 

mercury, etc, 309 
Prognosis, 20 



Purpura ha>raorrhagica, 83 

simple, 83 
Pus in urine, 220 
Pustular eruptions, 301 
Pustule, definition of, 294 
Pj-gemic abscess of liver, 204 
Pyelitis, 222 

Pylorus, stricture of, 170 
Pyrosis, 168 
Pythogenic fever, 27 

Quartan ague, 36 
Quinsy, 165 
Quotidian ague, 36 

Rabies, 289 
Rales, 93 

crepitant, 93 

moist, 93 

muco-crepitant, 95 

subcrepitant, 95 
Rash, typhoid, 28 

typhus, 23 
Red hepatization of lung, 124 

softening of brain, 252 
Relapsing fever, 33 
Remittent fever, 38 
Renal calculus, 236 

colic, 236 

dropsy, 60 
Resolvents, 310 
Respiration, amphoric, 139 

bronchial, 92 

cavernous, 91 

puerile, 126, 132 

tracheal. 91 

tubular, 92 
Respiratory organs, diseases of, 91 
Retrocedent gout, 77 



Progressive muscular atrophy, 265 Rheumatism, 70 

Progressive paralysis of the insane, j Rhonchi, sibilant and sonorous, 93 



261 

Prurigo, 302 

Psoriasis, 303 

Ptosis, 264 

Puerile breathing, 133 

Pulmonary cancer, 142 
consumption, 136 
emphysema, 1 18 
valves, disease of, 157 

Purgatives, 314 

Purpura, 82 

diagnosis of, 84 



Roseola, 297 

Rotheln, 56 

Roundworms, 191 

Rubeola, 56 

Rupia, 300 

Rusty sputum of pneumonia, 123 

Saint Vitus's dance, 274 
Salicin in rheumatism, 74 
Salines, 321 
Sarcinae ventriculi, 168 
Scabies, 306 



29 



334 



INDEX. 



Scale, description of, 295 
Scarlatina, 49 
anginosa, 50 
maligna, 50 
simplex, 49 
Scarlatinal dropsy, 51 
Scarlet fever, 49 
Sciatica, 268 
Sclerosis, cerebral, 252 
Selerostoma duodenale, 192 
Scorbutus, 79 
Scrofula, 62 
Scrofulous diathesis, 65 
Scurvy, 79 

diagnosis of, 84 
Sedatives, 321 
Senile emphysema, 120 
Shingles, 298 
Sibilant rhonchi, 93 
Simple atrophy of heart. 147 
of liver, 206 
erysipelas, 87 
fever, 21 
hypertrophy of heart, 144 

of liver, 202 
scarlatina, 49 
Skin, diseases of, 292 

classification of, 295 
syphilitic, 69 
Small-pox, 44 

confluent, 45 
Softening of the brain, 252 

spinal cord, 284 
Sonorous rhonchi, 93 
Spasm of the glottis, 106 
Spasmodic asthma, 121 

croup, 106 
Specific gravity of urine, 218 
Spinal cord, congestion of, 284 
diseases of, 283 
haemorrhage into, 284 
inflammation of, 283 
softening of, 284 
Spinal irritation, 285 
meningitis, 283 
Spleen, ague cake of, 37, 213 
diseases of, 212 
relapsing abscess of, 34 
Spurious croup, 106 
Sputa, lung-tissue in, 140 
Squamous eruptions, 303 
Stimulants, 322 



Stomach, cancer of, 172 

diseases of, 166 

perforation of, 170, 171 

ulcer of, 169 
Stomatitis, 164 
Stricture of intestine, 176 

of oesophagus, 166 

of pylorus, 170, 173 
Stroke, paralytic, 261 
Strumous diathesis. 65 

dyspepsia, 65 
Strychnia, preparations contain- 
ing, 310 
Subcrepitant rales, 95 
Sudamina, 298 
Sugar in urine, 240 
Sunstroke, 279 
Suppurative nephritis, 222 
Suprarenal capsule, disease of, 

216 
Sycosis menti, 307 
Symptomatic asthma, 121 
Syphilis, 67 

of brain, 259 

of liver, 68 
Syphilitic ulcer on tongue, 163 

Tabes mesenterica, 66 
Taenia, 189 

echinococcus, 201 

mediocanellata, 190 

solium, 189 
Tapeworm, 189 

Temperature in apoplectic seiz- 
ures, 248 

in fevers, 21, 24, 28, 34,50, 54 

normal, 21 

in phthisis, 138 

in pneumonia, 123 

in rheumatism, 72 
Tenesmus, 182 
Tertian ague, 36 
Testicle, syphilitic tumors of, 68 
Tests for albumen in urine, 220 
pus in urine, 220 
sugar in urine, 240 
Tetanus, 291 

Thermometer, mode of using, 21 
Third nerve, paralysis of, 264 
Thoracic aorta, aneurism of, 159 
Threadworms, 192 



INDEX. 



335 



Thrombosis and embolism, cere- 
bral, 246 
Thrush, the 164 
Tic douloureux, 268 
Tinea cireinata, 307 

decalvans, 308 

favosa, 307 

sycosis. 307 

tonsurans, 307 

tricophytina, 307 

versicolor, 308 
Tongue, diseases of, 163 
Tonics. 323 
Tonsillitis, 165 
Tophi. 76 

Tracheal respiration, 91 
Tracheotomy, 97, 105 
Traumatic erysipelas, 87 

tetanus, 291 
Treatment, general and prophy- 
lactic, 20 
Trichina spiralis, 193 
Trichinosis, 193 
Tricocephalus dispar, 192 
Tricuspid valves, diseases of. 157 
Tropical abscess of liver, 204 
True croup, 102 
Tube-casts in urine, 219 
Tubercle, 63 

calcification of, 64 

degeneration of, 64 

gray, 63 

miliary, 63 

of brain. 257 

of kidneys, 237 

of lungs, 63, 136 

yellow, 63 
Tubercular eruptions, 296, 304 

meningitis, 257 

mesenteric disease, 66 

peritonitis, 196 
Tuberculosis, 62 

symptoms of, 64 

treatment of, 66 
Tubular breathing. 92 
Tumors of brain, 259 

of larynx, 97 
Tympanitis. 60 
Typhlitis, 197 
Typhoid fever, 27 

diagnosis of, 30 

ulcer, 29 



Typhus fever, 23 

diagnosis of, 26 

Ulceration of stomach, 169 

syphilitic, 68 
Ulcers of the intestine, dysenteric, 
181 
typhoid, 29 

of the larynx, 97 

of the tongue, 163 
Uraemia, 231 
Uric acid in urine, 218 
Urinary calculus, 236 

deposits, 218 
Urine, albumen in, 220 

amorphous urates in, 218 

blood in, 220. 234 

casts in 219 

chylous, 233 

epithelium in, 218 

mucus in. 223 

oxalate of lime in, 219 

pus in, 220 

specific gravity of, 218 

sugar in, 240 

triple phosphates in, 218 

uric acid in, 219 
Urinometer, 218 
Urticaria, 297 

Vaccination, 48 
Varicella, 48 
Variola, 44 

confluens, 45 

discreta, 45 
Valves of heart, diseases cf, 152, 

155 
Vegetable parasites, 307 
Vesicle, definition of, 293 
Vesicular eruptions, 298 

murmur, 92 
Vibices, 82 
Vocal fremitus. 95 

resonance, 92 
Vomiting, 167 

of blood, 137, 170 
Vox choleraica, 187 

Walcheren fever, 38 
Walls of abdomen, 17, 18 
of chest, 15, 16 



-r 



336 



INM1X. 



Wasting palsy, 265 
Water in the head, 258 
Waxy kidney, 229 

liver, 200 
White softening of the brain, 252 
Worms, intestinal, 189 
Writer's cramp, 266 



Yellow atrophy of liver, 206 
fever, 40 

softening of brain, 252 
tubercle, 63 

Zoster, herpes, 298 
i Zymotic diseases, 19 



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